LETTERS TO THE EDITOR
Letters to the Editor
202
Oxford University Press 1992
Nepal should be taught about hypothermia and they should also be instructed in the use of rectal thermometers. R. B. JOHANSON, P. ROLFE, and S. A. SPENCER
North Staffordshire Health Authority and University of Keele R.
RAI
Lalitpur Community Health Development Program, United Mission to Nepal References 1. Johanson R, Malla DS, Rolfe PR, Spencer SA. The effect of postdelivery care on neonatal body temperature. Early Hum Dev 1990; 21: 132-3. 2. Johanson R, Malla DS, Tuladhar C, Amatya M, Rolfe PR, Spencer SA. A survey of technology and temperature on a neonatal unit in Kathmandu, Nepal. J Trop Pediat 1992 (in press). 3. Tafari N. Hypothermia in the tropics: epidemiologic aspects. In: Sterky G, Tafari N, Tunell R (eds). Breathing and warmth at birth. Judging the appropriateness of technology. Stockholm: SAREC Report R2, 1985.
Sir,
Prevention of Low Birth Weight—Rest is Best The causes of low birth weight are complex and multifactorial, and only some like maternal anaemia, maternal nutritional status and dietary intake during pregnancy have received attention,1 while other factors like effects of hot climate, upright posture, and exercise in pregnancy have remained virtually unexplored.2 The uteroplacental blood flow is a major determinant of fetal growth and it is probably through this channel that the amount of maternal rest contributes to determining the birth weight. Inconclusive evidence is to be found in the literature supporting the last statement.3""12 We carried out a study on 474 women delivering at term to study the relationship between maternal rest and birth weight. An hour to hour inventory of their activity and rest was made for the whole 24 hours. The hours were logged in a proforma for heavy work, moderate work, and light work. Similarly, hours of rest were logged for various grades of rest. The various hours of rest/activity were converted into 'scores' by using an arbitrary scoring system (Table 1), which were totalled to give rest and activity scores. The 'Rest minus Activity' (R —A score) gives us a measure of absolute rest taken by the woman. Theoretically, it will be seen from Table 1 that the range of R —A score could be from +120 (a woman sleeping for 24 hours) to —120 (a woman performing Journal of Tropical Pediatrics
Vol. 38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
Sir, Should Thermometers be Issued to Birth Attendants in Nepal? A high incidence of hypothermia both after birth and at discharge from the Kathmandu Maternity Hospital has been reported,1 where hypothermia was also a problem on the neonatal unit.2 Tafari3 noted a high mortality amongst the many babies admitted with neonatal cold injury to the Paediatric Clinic in Addis Ababa. We carried out a study of post-delivery temperature after home births in hillside villages south of Kathmandu. Two village health workers and a traditional birth attendant used standard mercury-in-glass thermometers which had been marked at the point where gradations began (35°C). The rectal temperature was recorded as being below, at, or above the mark. The workers were instructed by a 'traditional birth attendant' training programme supervisor (RR) in the technique of measurement. Twelve babies were studied, all born in the winter months of January to March 1989, with all of them being delivered between 1700 and 0800 hours. The measurements were undertaken within 12 hours of birth. None of the babies were described as being small by the investigators. At the time of measurement all the babies were said to be wellwrapped. In 58 per cent (7/12) of the babies the temperature was found to be below the mark (i.e. 35°C). Two of the traditional birth attendants delivering the babies were interviewed. Evidently, the baby was not immediately attended to after delivery. Instead, the delivery of the placenta was carried out. During this time the baby lay on the floor next to the mother (one of the attendants said that the child was placed on cloth). Only after the mother had been cared for was the baby washed and then clothed. In Nepal, as in many other countries, the vast majority of deliveries are undertaken at home, with a traditional birth attendant. No previous studies using village health workers or traditional birth attendants to record temperature after birth have been reported, either from Nepal or from any other developing countries. We found that a simplified procedure of temperature measurement could be taught to workers who could not read. The measurements obtained point to hypothermia being a problem in rural Nepal, with very few 'thermally beneficial' practices in traditionally attended births such as these. We believe that birth attendants in
LETTERS TO THE EDITOR
TABLE 1
Variable
Score
Activity Heavy work (manual labour) Moderate work (washing, sweeping) Light work (cooking, light household work)
5 per hour 3 per hour 1 per hour
5 per hour 3 per hour 1 per hour
TABLE 2
Co-efficient of correlation r for various R — A scores for different socio-economic groups (n = 474) R — A score Socio-economic group Group Group Group Group
I (n = 78) II (n = 216) III (n= 111) IV (n = 69)
60
0.21 -0.0003 -0.10 -0.26
0.33 0.61 0.20 -0.11
Department of Social and Preventive Medicine, Dayanand Medical College and Hospital Ludhiana (Pb.)—141001, India
References
heavy work for 24 hours). However, the actual study shows the majority of R — A scores ranged from 0 to + 90. On this basis the women were arbitrarily divided into the following groups, viz. R — A score of 30 or less, 31-60, and above 60. Women were also stratified according to their socio-economic status into four groups, the criteria being total family income of up to Rs. 1000 per month (Group I), Rs. 1001-2000 (Group II), Rs. 2001-3000 (Group III) and above Rs. 3000 (Group IV). To find the relationship between rest and birth weight, the co-efficient of correlation was calculated between R-A scores and birth weight (Table 2). Though overall a low degree of correlation was observed between maternal rest and activity, in the low socio-economic groups (Groups I and II) the correlation was strong. An interesting and important observation is that in all socio-economic groups the value of r increases with increasing R — A scores, i.e. birth weight increases with increasing maternal rest. The study demonstrates that maternal rest is an important determinant of birth weight, particularly in women of lower socio-economic group. A study from Aligarh2 has also shown that inadequate and improper maternal rest is an important factor in intra-uterine growth retardation. The same study has Journal of Tropical Pediatrics
Vol.38
August 1992
1. Raman L. Effect of maternal nutrition on foetal development and on neonatal outcome. Ann Natl Acad Med Sci (Ind) 1989; 25: 57. 2. Faridi MMA, Ali R, Sacena K, fewari K, Adhami S, Bhargava SK. Effect of maternal rest on foetal growth. Ann Natl Acad Med Sci (Ind) 1989; 25: 61. 3. Gruenwald P. The supply line of the fetus: definitions relating to fetal growth. In: Gruenwald P (ed.) The placenta and its maternal supply line. Medical and Technical Publishing Co Ltd 1975; 1-17, 186-96. 4. Levene MI, Tudehope D, Thearle J. Fetal physiology, assessment of fetal wellbeing and adaptation to extrauterine life. In: Essentials of neonatal medicine. Baltimore: Blackwell Scientific Publications, 1987; 6-15. 5. Rodeck CH, Nicolin U. Physiology of the mid-trimester foetus. In: Whitelas A, Cook RWI (eds). The very immature infant less than 28 weeks gestation. Br Med Bull 1988; 44: 826-49. 6. Felig P. Maternal and fetal fuel homeostasis in human pregnancy. Am J Clin Nutr 1973; 26: 998-1005. 7. Felig P, Kim YJ, Lynch V, Hendler R. Amino acid metabolism during starvation in human pregnancy. J Clin Invest 1972; 51: 1195-202. 8. Hull D. Storage and supply of fatty acids before and after birth. Br Med Bull 1975; 31: 32-6. 9. Battaglia FC, Meschia G. Principal substrates of fetal metabolism. Physio! Rev 1978; 58: 499-527. 10. Pernoll ML, Metcalfe TL, Schlenker JE, Welch JE, Matsumoto JA. Oxygen consumption at rest and during exercise. Respir Physiol 1975; 25: 285-93. 11. Pomerance JJ, Gluck L, Lynch VA. Maternal exercise 203
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
Rest Grade I (sleep) Grade II (lying down) Grade III (idling, sitting, knitting)
also shown that the birth weight of term AGA babies was directly affected by maternal rest. Our present study shows that birth weight improves with increasing maternal rest. An earlier study from Ethiopia 13 has also shown that birth weight is influenced by maternal rest when food intake is restricted. This study supports our finding of higher degree of correlation between rest and birth weight in mothers of poor socio-economic group where diets are likely to be of a poor nutritive value. Yet another study from USA 14 has shown that birth weight of children born to women who worked in the third trimester weighed 150-400 g less than the newborn of mothers who rested at home, thus, further substantiating the present findings. Since the incidence of low birth weight is high in our country and diets of pregnant women are generally poor in quantity, any programme for prevention of low birth weight must emphasize adequate maternal rest throughout pregnancy to restrict energy expenditure, particularly for women from the low socio-economic strata.
LETTERS TO THE EDITOR
as a screening test for uteroplacental insufficiency. Obstet Gynecol 1974; 44: 385-7. 12. Naeye RL. New observations in erythroblastosis fetalis. J Am Med Ass 1967; 200: 281-6. 13. Tafari N, Naeye RL, Gobezie A. Effects of maternal undernutrition and heavy physical work during pregnancy on birth weight. Br J Obstet Gynaecol 1980; 87: 222-6. 14. Naeye RL, Peters, EC. Working during pregnancy: effects on the fetus. Pediatrics 1982; 69: 724-7.
feeding in the Schools of Nursing and Midwifery. Excellent guidelines suggested by the International Union of Nutrition Sciences could be used for such training.5 A. I. OSINAIKE and G. A. OYEDEJI
Department of Paediatrics and Child Health, Obafemi Awolowo University Teaching Hospitals Complex,
rie-Ife, Nigeria S. A. OLOWE
Health workers are partly responsible for the decline in breastfeeding practices in many countries.1'2 In Nigeria, nurses and midwives play vital roles in maternal and child health services. They represent a potentially powerful force capable of influencing breastfeeding practices in the community in which they live and work. Mudambi noted that 47 per cent of mid-western Nigerian mothers were advised by their nurses and midwives to use breastmilk substitutes even when breastmilk was sufficient.3 A study was set up to document how knowledgeable this influential group of health workers are about breastfeeding and to suggest ways of improving such knowledge if found to be defective. The subjects were 202 randomly selected trained nurses and midwives working in the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) and the Primary Health Centres (PHC) in Ile-Ife and Ilesa as well as female tutors of the Schools of Nursing and Midwifery of the Obafemi Awolowo University Teaching Hospitals Complex. Their knowledge about breastfeeding was studied by means of a questionnaire. The age of the respondents ranged between 21 and 50 years, 86 per cent were married and 85 per cent had borne children. The mean parity was 3. Only about half of the respondents have good knowledge of breastfeeding and its practical management. The teaching hospital staff were significantly more knowledgeable than those who work in the primary Health Centres (P< 0.005). Respondents with double professional qualification were also significantly more knowledgeable than those with single qualification (/>< 0.005). It has been suggested that if the health worker is to manage lactation well she must have the right attitude to breastfeeding and also possess thorough knowledge about the physiological mechanism involved.4 It therefore follows that any effort at promoting breastfeeding in Nigeria should include improving the knowledge of the nurses and midwives concerning breastfeeding. More time should be devoted to the teaching of the practical management of breast-
Growth Pattern of Urban Malaysian Infants Much has been reported on the importance of growth pattern and its implications on public health both in developing and developed countries. Waterlow et al.1 revealed the rate of weight growth of infants in developing countries declines sharply compared with a reference population age 3-4 months, if not earlier. This pattern of faltering growth was attributed to insufficent nutrient intake especially from breastmilk, increased exposure to infections or both.2'3 There has been much controversies regarding the validity of the use of international standards in developing countries.4"7 There must be a way to check these controversies. This longitudinal study on growth in weight and length of small group of infants is intended to see whether the growth pattern follows the NCHS reference standards. Growth in this group of infants compares well with the international standards for the first 6 months of life. Despite the fact that these infants maintain a relatively high weight for age through the first 6 months, it should be emphasized that they do follow the pattern typical of developing countries in experiencing a decline in weight gain thereafter. Chen has shown that Malay-
204
Journal of Tropical Pediatrics
References 1. Hollen BK. Attitude and practices of physicians concerning breast feeding and its management. J Trop Pediat Env Child Hlth 1976; 22: 288-93. 2. Burgess AP. Breast feeding: the knowledge and attitudes of some health personnel in metropolitan Manila. J Trop Pediat 1980; 26: 168-71. 3. Mudambi ST. Breast feeding practices and mothers from mid-western Nigeria. J Trop Pediat 1981; 27: 96-100. 4. Ebrahim GJ. Breast feeding—the biological option. Hong Kong: ELBS and MacMillan Press (Publishers) Ltd, 1980. 5. Jelliffe EF (ed.). Guidelines for training of nurses and midwives as lactation counsellors, International Union of Nutrition Sciences Committee IV/6. UNICEF, 1989. Sir,
Vol. 38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
Sir, 77ie Knowledge of Nurses and Midwives in He-Ife and Ilesa (Nigeria) Concerning Breastfeeding
LETTERS TO THE EDITOR
5. 6. 7. 8.
9. 10. 11. 12.
13.
national anthropometric standards appropriate for Developing countries? J Trop Pediat 1991; 37: 37-44. Goldstein H, Tanner JM. Child growth standards. Lancet 1980; ii: 35. Graitcher PL, Gentry EM. Measuring children: one reference for all. Lancet 1981; ii: 297. Waterlow JC. Child growth standards. Lancet 1980; ii: 717. Chen ST. The assessment of physical growth and development from birth to two years of age in a selected group of Malay children from higher income families. MD Thesis, University Malaya 1983; 68-211. Bindon JR, Pelletier DL. Patterns of growth in weight among infants in a rural Western Samoa village. Ecol Food Nutr 1986; 18: 135-43. Duncan B, Schaefer C, Sibley B, Fonseca NM. Reduced growth velocity in exclusively breast-fed infants. Am J Dis Childh 1984; 138: 309-13. Hitchcock NE, Gracey M, Gilmour AI. The growth of breast fed and artificially fed infants from birth to twelve months. Acta Paediat Scand 1985; 74: 240-5. Whitehead RG, Paul AA, Ahmed EA. Weaning practices in the United Kingdom and variations in anthropometric development. Acta Paediat Scand Suppl 1986; 323: 14-23. Pelletier DL, Bindon JR. Patterns of growth in weight and length among American Samoan infants. Ecol Food Nutr 1985; 18: 145-57.
ZAWIAH HASHIM
Department of Food Science and Nutrition, Faculty of Life Sciences, Universiti Kebangsaan Malaysia, 43600 Bangi, Selangor Darul Ehsan, Malaysia
References 1. Waterlow JC, Ashworth A, Griffiths M. Faltering infant growth in less-developed countries. Lancet 1980; ii: 1176-8. 2. Martorell R, Leslie J, Mooch PR. Characteristics and determinants of child nutritional status in Nepal. Am J Clin Nutr 1984; 39: 74-86. 3. Underwood BA, Hofvander Y. Appropriate timing for complementary feeding of the breastfed infant: A review. Acta Paediatr Scand Suppl 1982; 294: 5-32. 4. Kow F, Geissler C, Balasubramaniam E. Are InterJournal of Tropical Pediatrics
Vol. 38
August 1992
205
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
sians, like other Asians are smaller in size with relatively shorter legs and less body fat compared with children of European ancestry.8 Most investigations have revealed a tendency for the infants weight to fall off a little after 3-4 months compared with the usual growth standard,9 but whether this is of any importance is not known. This, however, coincides with the time when solid food was introduced. Recent evidence from affluent societies has shown similar differences in growth patterns of exclusively formula-fed and breastfed infants during the first 6 months.10-12 With the present data, it is difficult to identify the factors responsible for the rapid growth in weight gain in early infancy. What the data do suggest is that weight gain is as rapid with any feeding regimens unlike the pattern presented in developed countries where formula-fed infants typically gain weight faster than breastfed infants.13 The general growth pattern is in agreement with reports that weight gain of infants in developing countries is commonly found to be adequate for the first 2-6 months of life, but declines rapidly thereafter and resulted in levels of attained weight well below norms for developed countries by the end of the first year. Are we going to continue accepting this as normal for developing countries or are we going to develop our own standards? Developing growth standards for Malaysia will be a difficult task due to the existence of a few ethnic groups. Do we need standards for every group? This study was not intended to be a representative sample; nevertheless, it is relevant to consider how it relates to the general population in Malaysia. Studies such as this would remind policy makers and parents that monitoring growth pattern of infant and children is highly desirable and that any undue acceleration or slowing down of growth will act as a trigger to have the child's general health evaluated.
Letters to the Editor
202
Oxford University Press 1992
Nepal should be taught about hypothermia and they should also be instructed in the use of rectal thermometers. R. B. JOHANSON, P. ROLFE, and S. A. SPENCER
North Staffordshire Health Authority and University of Keele R.
RAI
Lalitpur Community Health Development Program, United Mission to Nepal References 1. Johanson R, Malla DS, Rolfe PR, Spencer SA. The effect of postdelivery care on neonatal body temperature. Early Hum Dev 1990; 21: 132-3. 2. Johanson R, Malla DS, Tuladhar C, Amatya M, Rolfe PR, Spencer SA. A survey of technology and temperature on a neonatal unit in Kathmandu, Nepal. J Trop Pediat 1992 (in press). 3. Tafari N. Hypothermia in the tropics: epidemiologic aspects. In: Sterky G, Tafari N, Tunell R (eds). Breathing and warmth at birth. Judging the appropriateness of technology. Stockholm: SAREC Report R2, 1985.
Sir,
Prevention of Low Birth Weight—Rest is Best The causes of low birth weight are complex and multifactorial, and only some like maternal anaemia, maternal nutritional status and dietary intake during pregnancy have received attention,1 while other factors like effects of hot climate, upright posture, and exercise in pregnancy have remained virtually unexplored.2 The uteroplacental blood flow is a major determinant of fetal growth and it is probably through this channel that the amount of maternal rest contributes to determining the birth weight. Inconclusive evidence is to be found in the literature supporting the last statement.3""12 We carried out a study on 474 women delivering at term to study the relationship between maternal rest and birth weight. An hour to hour inventory of their activity and rest was made for the whole 24 hours. The hours were logged in a proforma for heavy work, moderate work, and light work. Similarly, hours of rest were logged for various grades of rest. The various hours of rest/activity were converted into 'scores' by using an arbitrary scoring system (Table 1), which were totalled to give rest and activity scores. The 'Rest minus Activity' (R —A score) gives us a measure of absolute rest taken by the woman. Theoretically, it will be seen from Table 1 that the range of R —A score could be from +120 (a woman sleeping for 24 hours) to —120 (a woman performing Journal of Tropical Pediatrics
Vol. 38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
Sir, Should Thermometers be Issued to Birth Attendants in Nepal? A high incidence of hypothermia both after birth and at discharge from the Kathmandu Maternity Hospital has been reported,1 where hypothermia was also a problem on the neonatal unit.2 Tafari3 noted a high mortality amongst the many babies admitted with neonatal cold injury to the Paediatric Clinic in Addis Ababa. We carried out a study of post-delivery temperature after home births in hillside villages south of Kathmandu. Two village health workers and a traditional birth attendant used standard mercury-in-glass thermometers which had been marked at the point where gradations began (35°C). The rectal temperature was recorded as being below, at, or above the mark. The workers were instructed by a 'traditional birth attendant' training programme supervisor (RR) in the technique of measurement. Twelve babies were studied, all born in the winter months of January to March 1989, with all of them being delivered between 1700 and 0800 hours. The measurements were undertaken within 12 hours of birth. None of the babies were described as being small by the investigators. At the time of measurement all the babies were said to be wellwrapped. In 58 per cent (7/12) of the babies the temperature was found to be below the mark (i.e. 35°C). Two of the traditional birth attendants delivering the babies were interviewed. Evidently, the baby was not immediately attended to after delivery. Instead, the delivery of the placenta was carried out. During this time the baby lay on the floor next to the mother (one of the attendants said that the child was placed on cloth). Only after the mother had been cared for was the baby washed and then clothed. In Nepal, as in many other countries, the vast majority of deliveries are undertaken at home, with a traditional birth attendant. No previous studies using village health workers or traditional birth attendants to record temperature after birth have been reported, either from Nepal or from any other developing countries. We found that a simplified procedure of temperature measurement could be taught to workers who could not read. The measurements obtained point to hypothermia being a problem in rural Nepal, with very few 'thermally beneficial' practices in traditionally attended births such as these. We believe that birth attendants in
LETTERS TO THE EDITOR
TABLE 1
Variable
Score
Activity Heavy work (manual labour) Moderate work (washing, sweeping) Light work (cooking, light household work)
5 per hour 3 per hour 1 per hour
5 per hour 3 per hour 1 per hour
TABLE 2
Co-efficient of correlation r for various R — A scores for different socio-economic groups (n = 474) R — A score Socio-economic group Group Group Group Group
I (n = 78) II (n = 216) III (n= 111) IV (n = 69)
60
0.21 -0.0003 -0.10 -0.26
0.33 0.61 0.20 -0.11
Department of Social and Preventive Medicine, Dayanand Medical College and Hospital Ludhiana (Pb.)—141001, India
References
heavy work for 24 hours). However, the actual study shows the majority of R — A scores ranged from 0 to + 90. On this basis the women were arbitrarily divided into the following groups, viz. R — A score of 30 or less, 31-60, and above 60. Women were also stratified according to their socio-economic status into four groups, the criteria being total family income of up to Rs. 1000 per month (Group I), Rs. 1001-2000 (Group II), Rs. 2001-3000 (Group III) and above Rs. 3000 (Group IV). To find the relationship between rest and birth weight, the co-efficient of correlation was calculated between R-A scores and birth weight (Table 2). Though overall a low degree of correlation was observed between maternal rest and activity, in the low socio-economic groups (Groups I and II) the correlation was strong. An interesting and important observation is that in all socio-economic groups the value of r increases with increasing R — A scores, i.e. birth weight increases with increasing maternal rest. The study demonstrates that maternal rest is an important determinant of birth weight, particularly in women of lower socio-economic group. A study from Aligarh2 has also shown that inadequate and improper maternal rest is an important factor in intra-uterine growth retardation. The same study has Journal of Tropical Pediatrics
Vol.38
August 1992
1. Raman L. Effect of maternal nutrition on foetal development and on neonatal outcome. Ann Natl Acad Med Sci (Ind) 1989; 25: 57. 2. Faridi MMA, Ali R, Sacena K, fewari K, Adhami S, Bhargava SK. Effect of maternal rest on foetal growth. Ann Natl Acad Med Sci (Ind) 1989; 25: 61. 3. Gruenwald P. The supply line of the fetus: definitions relating to fetal growth. In: Gruenwald P (ed.) The placenta and its maternal supply line. Medical and Technical Publishing Co Ltd 1975; 1-17, 186-96. 4. Levene MI, Tudehope D, Thearle J. Fetal physiology, assessment of fetal wellbeing and adaptation to extrauterine life. In: Essentials of neonatal medicine. Baltimore: Blackwell Scientific Publications, 1987; 6-15. 5. Rodeck CH, Nicolin U. Physiology of the mid-trimester foetus. In: Whitelas A, Cook RWI (eds). The very immature infant less than 28 weeks gestation. Br Med Bull 1988; 44: 826-49. 6. Felig P. Maternal and fetal fuel homeostasis in human pregnancy. Am J Clin Nutr 1973; 26: 998-1005. 7. Felig P, Kim YJ, Lynch V, Hendler R. Amino acid metabolism during starvation in human pregnancy. J Clin Invest 1972; 51: 1195-202. 8. Hull D. Storage and supply of fatty acids before and after birth. Br Med Bull 1975; 31: 32-6. 9. Battaglia FC, Meschia G. Principal substrates of fetal metabolism. Physio! Rev 1978; 58: 499-527. 10. Pernoll ML, Metcalfe TL, Schlenker JE, Welch JE, Matsumoto JA. Oxygen consumption at rest and during exercise. Respir Physiol 1975; 25: 285-93. 11. Pomerance JJ, Gluck L, Lynch VA. Maternal exercise 203
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
Rest Grade I (sleep) Grade II (lying down) Grade III (idling, sitting, knitting)
also shown that the birth weight of term AGA babies was directly affected by maternal rest. Our present study shows that birth weight improves with increasing maternal rest. An earlier study from Ethiopia 13 has also shown that birth weight is influenced by maternal rest when food intake is restricted. This study supports our finding of higher degree of correlation between rest and birth weight in mothers of poor socio-economic group where diets are likely to be of a poor nutritive value. Yet another study from USA 14 has shown that birth weight of children born to women who worked in the third trimester weighed 150-400 g less than the newborn of mothers who rested at home, thus, further substantiating the present findings. Since the incidence of low birth weight is high in our country and diets of pregnant women are generally poor in quantity, any programme for prevention of low birth weight must emphasize adequate maternal rest throughout pregnancy to restrict energy expenditure, particularly for women from the low socio-economic strata.
LETTERS TO THE EDITOR
as a screening test for uteroplacental insufficiency. Obstet Gynecol 1974; 44: 385-7. 12. Naeye RL. New observations in erythroblastosis fetalis. J Am Med Ass 1967; 200: 281-6. 13. Tafari N, Naeye RL, Gobezie A. Effects of maternal undernutrition and heavy physical work during pregnancy on birth weight. Br J Obstet Gynaecol 1980; 87: 222-6. 14. Naeye RL, Peters, EC. Working during pregnancy: effects on the fetus. Pediatrics 1982; 69: 724-7.
feeding in the Schools of Nursing and Midwifery. Excellent guidelines suggested by the International Union of Nutrition Sciences could be used for such training.5 A. I. OSINAIKE and G. A. OYEDEJI
Department of Paediatrics and Child Health, Obafemi Awolowo University Teaching Hospitals Complex,
rie-Ife, Nigeria S. A. OLOWE
Health workers are partly responsible for the decline in breastfeeding practices in many countries.1'2 In Nigeria, nurses and midwives play vital roles in maternal and child health services. They represent a potentially powerful force capable of influencing breastfeeding practices in the community in which they live and work. Mudambi noted that 47 per cent of mid-western Nigerian mothers were advised by their nurses and midwives to use breastmilk substitutes even when breastmilk was sufficient.3 A study was set up to document how knowledgeable this influential group of health workers are about breastfeeding and to suggest ways of improving such knowledge if found to be defective. The subjects were 202 randomly selected trained nurses and midwives working in the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) and the Primary Health Centres (PHC) in Ile-Ife and Ilesa as well as female tutors of the Schools of Nursing and Midwifery of the Obafemi Awolowo University Teaching Hospitals Complex. Their knowledge about breastfeeding was studied by means of a questionnaire. The age of the respondents ranged between 21 and 50 years, 86 per cent were married and 85 per cent had borne children. The mean parity was 3. Only about half of the respondents have good knowledge of breastfeeding and its practical management. The teaching hospital staff were significantly more knowledgeable than those who work in the primary Health Centres (P< 0.005). Respondents with double professional qualification were also significantly more knowledgeable than those with single qualification (/>< 0.005). It has been suggested that if the health worker is to manage lactation well she must have the right attitude to breastfeeding and also possess thorough knowledge about the physiological mechanism involved.4 It therefore follows that any effort at promoting breastfeeding in Nigeria should include improving the knowledge of the nurses and midwives concerning breastfeeding. More time should be devoted to the teaching of the practical management of breast-
Growth Pattern of Urban Malaysian Infants Much has been reported on the importance of growth pattern and its implications on public health both in developing and developed countries. Waterlow et al.1 revealed the rate of weight growth of infants in developing countries declines sharply compared with a reference population age 3-4 months, if not earlier. This pattern of faltering growth was attributed to insufficent nutrient intake especially from breastmilk, increased exposure to infections or both.2'3 There has been much controversies regarding the validity of the use of international standards in developing countries.4"7 There must be a way to check these controversies. This longitudinal study on growth in weight and length of small group of infants is intended to see whether the growth pattern follows the NCHS reference standards. Growth in this group of infants compares well with the international standards for the first 6 months of life. Despite the fact that these infants maintain a relatively high weight for age through the first 6 months, it should be emphasized that they do follow the pattern typical of developing countries in experiencing a decline in weight gain thereafter. Chen has shown that Malay-
204
Journal of Tropical Pediatrics
References 1. Hollen BK. Attitude and practices of physicians concerning breast feeding and its management. J Trop Pediat Env Child Hlth 1976; 22: 288-93. 2. Burgess AP. Breast feeding: the knowledge and attitudes of some health personnel in metropolitan Manila. J Trop Pediat 1980; 26: 168-71. 3. Mudambi ST. Breast feeding practices and mothers from mid-western Nigeria. J Trop Pediat 1981; 27: 96-100. 4. Ebrahim GJ. Breast feeding—the biological option. Hong Kong: ELBS and MacMillan Press (Publishers) Ltd, 1980. 5. Jelliffe EF (ed.). Guidelines for training of nurses and midwives as lactation counsellors, International Union of Nutrition Sciences Committee IV/6. UNICEF, 1989. Sir,
Vol. 38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
Sir, 77ie Knowledge of Nurses and Midwives in He-Ife and Ilesa (Nigeria) Concerning Breastfeeding
LETTERS TO THE EDITOR
5. 6. 7. 8.
9. 10. 11. 12.
13.
national anthropometric standards appropriate for Developing countries? J Trop Pediat 1991; 37: 37-44. Goldstein H, Tanner JM. Child growth standards. Lancet 1980; ii: 35. Graitcher PL, Gentry EM. Measuring children: one reference for all. Lancet 1981; ii: 297. Waterlow JC. Child growth standards. Lancet 1980; ii: 717. Chen ST. The assessment of physical growth and development from birth to two years of age in a selected group of Malay children from higher income families. MD Thesis, University Malaya 1983; 68-211. Bindon JR, Pelletier DL. Patterns of growth in weight among infants in a rural Western Samoa village. Ecol Food Nutr 1986; 18: 135-43. Duncan B, Schaefer C, Sibley B, Fonseca NM. Reduced growth velocity in exclusively breast-fed infants. Am J Dis Childh 1984; 138: 309-13. Hitchcock NE, Gracey M, Gilmour AI. The growth of breast fed and artificially fed infants from birth to twelve months. Acta Paediat Scand 1985; 74: 240-5. Whitehead RG, Paul AA, Ahmed EA. Weaning practices in the United Kingdom and variations in anthropometric development. Acta Paediat Scand Suppl 1986; 323: 14-23. Pelletier DL, Bindon JR. Patterns of growth in weight and length among American Samoan infants. Ecol Food Nutr 1985; 18: 145-57.
ZAWIAH HASHIM
Department of Food Science and Nutrition, Faculty of Life Sciences, Universiti Kebangsaan Malaysia, 43600 Bangi, Selangor Darul Ehsan, Malaysia
References 1. Waterlow JC, Ashworth A, Griffiths M. Faltering infant growth in less-developed countries. Lancet 1980; ii: 1176-8. 2. Martorell R, Leslie J, Mooch PR. Characteristics and determinants of child nutritional status in Nepal. Am J Clin Nutr 1984; 39: 74-86. 3. Underwood BA, Hofvander Y. Appropriate timing for complementary feeding of the breastfed infant: A review. Acta Paediatr Scand Suppl 1982; 294: 5-32. 4. Kow F, Geissler C, Balasubramaniam E. Are InterJournal of Tropical Pediatrics
Vol. 38
August 1992
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Downloaded from http://tropej.oxfordjournals.org/ at University of California, San Fransisco on March 24, 2015
sians, like other Asians are smaller in size with relatively shorter legs and less body fat compared with children of European ancestry.8 Most investigations have revealed a tendency for the infants weight to fall off a little after 3-4 months compared with the usual growth standard,9 but whether this is of any importance is not known. This, however, coincides with the time when solid food was introduced. Recent evidence from affluent societies has shown similar differences in growth patterns of exclusively formula-fed and breastfed infants during the first 6 months.10-12 With the present data, it is difficult to identify the factors responsible for the rapid growth in weight gain in early infancy. What the data do suggest is that weight gain is as rapid with any feeding regimens unlike the pattern presented in developed countries where formula-fed infants typically gain weight faster than breastfed infants.13 The general growth pattern is in agreement with reports that weight gain of infants in developing countries is commonly found to be adequate for the first 2-6 months of life, but declines rapidly thereafter and resulted in levels of attained weight well below norms for developed countries by the end of the first year. Are we going to continue accepting this as normal for developing countries or are we going to develop our own standards? Developing growth standards for Malaysia will be a difficult task due to the existence of a few ethnic groups. Do we need standards for every group? This study was not intended to be a representative sample; nevertheless, it is relevant to consider how it relates to the general population in Malaysia. Studies such as this would remind policy makers and parents that monitoring growth pattern of infant and children is highly desirable and that any undue acceleration or slowing down of growth will act as a trigger to have the child's general health evaluated.
