| Abstract|| |
A diversity in infant feeding patterns exists throughout the Middle East. Wide variations in cultures, languages, ethnic background, religions and social practices should be taken into consideration, when designing programs to promote appropriate feeding practices. Strategies applied in one community might not be appropriate for another. In order to be effective, these should be incorporated into overall primary health care programs.
|How to cite this article:|
Galal O. Child feeding patterns in the Middle East. Saudi J Gastroenterol 1995;1:138-44
The Middle East represents one of the most studied, but often least understood, regions of the world. It has traditionally been considered by many, to be a zone of predictable homogeneity, in terms of religion, geography, culture, and society. Indeed, many residents of the Middle East are linked by a common Arabic language, predominant Muslim identity, and profound respect for community and family. Notwithstanding these generalities, though, the Middle East is an area of remarkable diversity, encompassing more than 380 million people across 2 continents and 21 nations. More than 50% of the region is actually comprised of non-Arab ethnic groups, including Persians, Kurds, Jews, Druze, and others, who speak a rich variety of languages and have proud religious and cultural heritages, that are centuries old.
With the approach of the 21st century, though, all the societies in the Middle East are becoming exposed to even greater diversity,as they experience the gains and strains of rapid industrialization and Westernization. These "modernization" factors have had a profound impact on the traditional cultures of the Middle East.Shared traits and regional averages obscure important differences among key socio-economic characteristics in the region,particularly with the discovery of oil in the eastern portion of the region. Per capita income in the United Arab Emirates, for example, is 43 times higher than that of its neighbor Yemen, one of the poorest countries. Economic systems also vary throughout the region. The wealthiest gulf states rely primarily on oil revenues,while "middle income" countries such as Jordan, Lebanon, Syria, and Tunisia have developed labor-intensive industrial and service sectors to generate income (Jacobson, 1994). In contrast, the "lowest-income" nations in the region, such as Somalia, Yemen, and Mauritania, have economies that still function overwhelmingly on subsistence agriculture . Large disparities also exist throughout the Middle East in terms of total fertility rates, where women give birth to an average of 6 children each, in countries such as
Saudi Arabia and Syria, but only approximately 3 each, in Tunisia and Turkey. These examples demonstrate but a few of the profound cultural, social, and economic revolutions occurring within the region today.
| Traditional Infant Feeding Practices in the Middle East|| |
The Middle East, thus, represents a region where social practices have always been diverse, but nonetheless rooted in their own traditions. As noted, though, many aspects of the regions' cultural heritage are becoming even more divergent today with increased industrialization and Westernization. These shifts can be seen even among some of the most elementary components of a culture, such as the practices utilized by mothers to feed their young babies. Indeed, transitions in infant feeding patterns can serve as important indicators for larger, more significant changes occurring within family structures and societies as wholes .
More importantly, trends in infant feeding practices are important to explore in, and of themselves, because of their potential impact on the health and well-being of children and their families. The World Health Organization, for example, estimates that more than 1,000,000 children's lives could be saved each year, if more mothers would select breast-feeding over formula-feeding for their young infants. Leading health agencies (UNICEF, 1995) strongly recommend breast-feeding promotion as a core component of primary health care programs, and recognize the superiority of breast-feeding over formula-feeding for the physical, developmental, nutritional, mental, and emotional health of the mother and child. Provision of appropriate weaning foods can also help prevent morbidity and mortality due to nutrition-related diseases such as marasmus, kwashiorkor, rickets, scurvy, beriberi, xerophthalmia, and others.
Traditional infant feeding practices within the Middle East have overwhelmingly focused on breast-feeding as the primary method of providing nutrition to young babies. Like many developing regions around the world, women in the Middle East were historically recognized for prolonged duration of breast-feeding and strong societal support for the practice. Breast-feeding was traditionally held in high esteem, and believed by many mothers in the region to be far more than just the optimal source of nutrition for their infants. Indeed, breast-feeding was generally deemed to be a method of protecting young children from infectious diseases; a way to impart desirous parental personality traits to babies; and a process to establish kinship lines and familial bonding . Perhaps unique among all the worlds's major religions, Islam even went so far as to formally recognize the fundamental value of breast-feeding for the welfare of children, the family, and society in the Middle East by mandating in the Holy Koran that mothers nurse their infants for two years. Islam also prohibited marriage between children breast-feed by the same woman because of the belief that nursing was critical in establishing lines of kinship . Overall, most researchers report that the vast majority of mothers in the region, both urban and rural, have traditionally believed that the ability to breast-feed is a blessing, and it is a practice that requires maturity, patience, and a sense of responsibility .
| Current Trends in Infant Feeding Patterns in the Middle East|| |
As the Middle East experiences unprecedented social changes throughout recent decades, infant patterns in the region have reacted correspondingly. Various methods of feeding young babies that are prevalent in many communities in the Middle East today present serious health concerns for infants, and to a certain extent, their mothers. Overall, a number a trends appear to be prevalent throughout large areas of the region. For example, breast-feeding is declining in many communities of the Middle East, with levels of exclusive and total duration rates, generally below minimal guidelines recommended by leading health agencies. The use of supplementary liquids in addition to breastmilk also appears to be quite prevalent now, particularly considering the growing availability of infant formula and other commercial products. Additionally, weaning foods in many communities in the region are initiated earlier than necessary and may be of nutritionally-inferior quality. Following is a review of some of these new infant feeding concerns in the Middle East.
A. Patterns of colostrum provision and prelacteal feeds
Colostrum is the "first milk" a mother produces, and is generally a yellowish liquid that is discharged from the breast during the first days before "true milk" is produced. Colostrum is extremely high in protein and a number of important nutrients; it provides an easily-usable and concentrated source of food for newborns. However, cultural beliefs and Western-style obstetrical practices such as separation of mother and child after birth can sometimes result in' mothers preventing their infants from receiving this valuable "pre-milk" . Within other societies, prelacteal feeds are common, whereby infants are given various liquids before being allowed to nurse for the first time. Such practices, as the discarding of colostrum and the feeding of prelacteal liquids can have negative health consequences for infants, impact their nutritional status, and make them more susceptible to infectious diseases and diarrhea . These practices also reduce sucking stimulation of the breast, which can often lead to painful engorgement, milk insufficiency, and possible early termination of breast-feeding . Initiation of breast-feeding within several hours after child's birth increases the likelihood of exclusive breast-feeding; also lengthens and longer duration of breast-feeding .
Within the Middle East, these practices appear to occur in some communities. For instance, while more than 91% of mothers interviewed in the Sudan reported giving colostrum to their newborns, researchers documented that in rural Egypt, more than 30% of mothers actually discarded the valuable fluid. Likewise, in Egypt, 60% of the infants were prelacteally fed sugar water, teas, or both which were considered by the women to be necessary in cases of maternal exhaustion after delivery or perceived milk insufficiency. In the Sudan, 20% of mothers in some rural communities reported rubbing the newborn's mouth with fat and sorghum flour before initiating breast-feeding; boiled water with sugar and salt is regularly provided to the infant during the first few days of life as a colostrum.supplement by many in that country .
Furthermore, Western-style obstetrical practices in private hospitals in countries ranging from Jordan to Saudi Arabia, particularly those that separate the mother and child after birth,have also been shown to reduce early colostrum intake and increase the likelihood of supplemental liquids being provided to newborns,.
B. Exclusive breast feeding patterns
The United Nations Children's Fund (1994) recommends that infants be "exclusively breastfed", with no other supplements whatsoever, until four to six months of age. This practice helps ensure a sanitary, easily-digestible, optimal form of nutrition for human infants that also provides passive immunity against infections. The foundations for maternal and child-bonding are also laid at this time, and nursing in the post-partum period greatly assists the mother in recovering from birth.
Despite the well-documented benefits of exclusive breast-feeding though;, it is not widely practiced within the Middle East today [Table - 1]. Rates vary by country, but all fall short of meeting minimal guidelines established by health agencies. Among the lowest-income countries of Mauritania, Yemen, and Sudan, whose children are likely in the greatest need of optimal nutrition, no more than 15% of the mothers breast-feed exclusively while under four months (UNICEF, 1994). Even in moderate-income nations, though, the prevalence still does not meet recommended guidelines,with only 32% of Jordanian and 48% of Moroccan infants,exclusively nursing while under four months of age (UNICEF, 1994).
C. Use of supplementary liquids
The use of supplementary liquids appears to be quite prevalent in the Middle East, and is likely related to the low rates of exclusive breast-feeding. Providing infants with supplementary liquids while under four months of age is not recommended for several reasons . These liquids are inevitably of nutritionally-inferior quality when compared with breastmilk. Supplementary liquids, particularly commercial infant formula, can be extremely expensive to purchase, and therefore reduce the amount of money available to buy other products. The provision of supplementary liquids also decreases the frequency of sucking, which can lead to milk insufficiency syndrome and early termination of breast-feeding. Additionally, if supplementary liquids such as infant formula are provided with unclean water supplies and dirty bottles,the risk of infant mortality from diarrhea and related diseases can be three to six times greater, than if the child is breast-fed exclusively. Indeed, up until 1979, in Egypt alone, half of all infant and childhood deaths were due to diarrheal diseases .
Despite these advantages, the provision of supplementary liquids appears to be quite widespread in the Middle East. Researchers in a poor urban neighborhood in Cairo reported that supplementation with sugar water begins very early. Gradual introduction of other liquids and some solids is generally initiated after 40 days of age, as mixed formula and breast-feeding is commonly perceived to increase the nutritional quality of the child's diet . Another research has shown that 49 % of rural women in Egypt introduced other fluids to their children's diets by the first week of age.
Within Saudi Arabia, studies have shown that although 98% of the children are breast-fed upon discharge from the hospital, nearly 70% had been given supplemental liquids within three days of delivery . Additional studies in a Riyadh population showed that by age 3 months, the average baby had consumed 6 of the 36 varieties of artificial milk available, although less than 14 % of the mothers bottle-feeding could read the formula instructions, and only 18% could prepare a bottle properly .
Western-style hospitals in the region themselves have also been active in providing supplementary liquids to newborns, such as in Tehran, where as many as 70% of neonates in delivery wards may receive commercial infant formula before discharge .
The financial cost of commercial infant formula in the Middle East can also be prohibitive, such as in Turkey, where exclusive artificial feeding of an infant is estimated to require 25% of the family's entire budget (Hedstrom, 1980); such funds could be better spent on more nutritionally-superior food stuffs for infants and their lactating mothers. Nonetheless, with modernization, the increasing ability of families to pay for infant formula has resulted in greater use of bottle-feeding, such as that seen among communities in Yemen .
D. Patterns of complete termination of breast feeding
In addition to exclusive breast-feeding of infants until four to six months of age, leading health agencies today are recommending that mothers continue to nurse their children while supplementing them with solid foods until at least two years of age. As such, weaning should be a gradual process (UNICEF, 1994). Prolonged, supplementary breast-feeding by well-nourished mothers helps ensure adequate and sanitary provision of critical macro- and micro-nutrients essential to the health of young children; and is critical for the proper development of the brain, oral cavity, and other components of young human bodies . Extended supplementary breast-feeding also cements an even stronger maternal and child bond, while providing emotional and psychological satisfaction to the diet .
Despite these advantages, and the recommendations of health professionals and the Koran alike, nursing through two years of age does not appear to be universal among many Middle Eastern societies [Table - 2]. Within Morocco, for instance, only 18% of mothers still nurse their children as of two years of age, with only 13% doing so, in Jordan. Although still low, higher prevalence of breast-feeding at two years of age can be seen among 44% of the mothers in the Sudan, and 52 % in Pakistan.
Studies have revealed a number of reasons for termination of breast-feeding in the Middle East. In general, the most widely-cited motivations for completely weaning from the breast, in countries as diverse as Egypt, Saudi Arabia, and Iran, are: a desire for another pregnancy and, a perception that breastmilk is insufficient ,,. Modernization has also impacted breast- feeding duration, with urban residence being associated with early termination of nursing in Lebanon and other Middle Eastern nations ,, particularly among city women employed outside the home ,. Poor urban women, though, like their rural counterparts, have generally been found to terminate breast-feeding due to a desire to become pregnant again ; while many urban elite mothers in the Middle East have expressed a desire to completely stop nursing due to the adverse effects of oral contraceptives .
Cultural beliefs and practices can also be important in the Middle East, in determining breastfeeding practices. For instance, some mothers in Egypt feel that prolonged nursing may predispose an infant to stubbornness; and weaning from the breast is believed necessary to prepare a child to understand that he cannot always have his way . Likewise, gender differences in breast-feeding of infants can also occur among some societies in the region. Researchers have documented that young girls in Egypt and Sudan may have the nutritional advantage of longer access to the breast, more gradual weaning, and more frequent feeding than boys, due to adult perceptions of the differential needs of boys and girls for socialization in societies with clear role differentiation by gender . Other studies have shown that stronglyreligious women in the region may breast-feed longer than those with weaker convictions; while women with better education living in highincome families may terminate nursing earlier ,. Furthermore,research has shown that some women will completely terminate breastfeeding because of a desire to fast during Ramadan .
Hospitals in Lebanon and other Middle Eastern countries which model their obstetrical practices and practitioner training along Western lines have also been shown to negatively impact breast-feeding duration through lack of support for nursing mothers, separation of mothers and newborns, and formula feeding by neonatal nurses .
E. Utilization of solid weaning foods
As with breast-feeding practices, the utilization of solid weaning foods throughout the Middle East varies greatly throughout communities, and is experiencing even greater patterns of change with modernization in the region. Provision of adequate quality and quantity of solid weaning foods, particularly during infancy, can be critical in ensuring optimal health and development throughout childhood. Appropriate weaning diets are also necessary to prevent diet-related diseases such as protein-energy malnutrition, marasmus, kwashiorkor, rickets, scurvy, beri-beri, pellagra, xerophthalmia, and others that can be endemic among some communities in the Middle East. Nevertheless, throughout much of the region, weaning diets appear to be nutritionally inadequate in that they rely too heavily on starchy carbohydrates and are limited in high-quality protein.
Researchers in Egypt documented, for instance, that weaning foods in general tended to be deficient in both macro-nutrients such as calories and protein, and micro-nutrients like vitamin A, iron, thiamine and ascorbic acid . Young pre-school children in poor neigborhoods in Tehran, Iran, were also shown to have diets nutritionally-inadequate, with more than 62% being deficient in calories and 15% short on protein . Other studies in Iran showed that infant diets were also significantly-deficient in vitamin B 6 , folacin, calcium, iron, zinc, and energy . Similarly, researchers documented that in Lebanon, weaning diets were generally inadequate in caloric intake and had a protein- content of relatively poor quality . Additionally, research on lactating women in some communities in the region has documented that weaning may often be abrupt, particularly when the mother becomes pregnant again, while material knowledge of appropriate solid foods and their preparation is often poor .
The types of foods provided infants in the Middle East can vary also. For example, many children in Egypt under 12 months of age are provided with vegetable soup, cooked legumes, milk pudding, and sugared starch gruels; by age 24 months, other starchy foods are added, although eggs and proteins are not necessarily given frequently . In Saudi Arabia, though, weaning with solid foods generally begins between five to seven months of age, and often consists initially of rice, bread, vegetable soup, and other high-carbohydrate foods with little protein . Some infants in the United Arab Emirates are not provided supplementary weaning foods until relatively late in the first year, while a starchy diet of rice and bread, lacking in significant protein or vegetables may be common by the second year .
A variety of factors appear to be associated with weaning diets in the Middle East. Socio-economic status, for instance, is among the most important predictors of quality of weaning diets cited in the literature. Lower socio-economic levels among families in the Middle East have been associated in some cases with a weaning diet that is inadequate in quality and quantity. Studies in Lebanon have also documented that weaning diets of young children may be significantly inadequate due to poor food supply availability, ignorance of proper food selection, and lack of means to obtain food . Socio-economic level can also impact the type of foods provided in weaning diets, with researchers documenting that richer Iranian women followed more Westernstyle nutrition beliefs and practices, than did their poorer counterparts .
With greater industrialization in the Middle East and larger numbers of people moving from rural to urban areas, more people are now relying on a market economy rather than subsistence farming for their foodstuffs. As a result, nutritionally-inferior diets for children have been documented in city slum areas in the region, such as those in Turkey . In contrast, urbanization can sometimes result in infant weaning diets that are richer in animal meat proteins than those of their rural counterparts, as in Bahrain .
Seasonal differences in infant feeding patterns may also occur in the region. In Iran, for instance, marasmus in poor neighborhoods in Tehran had a peak incidence in infants at age three months, and was more common during the warm season when diarrhea was frequent . Likewise, the diets of infants in Sudanese communities were also shown to be of marginal caloric levels during and after bad seasons.
Also, local beliefs such as the notion that animal foods lead to putrefaction in young children's abdomens can be associated with lower provision of protein items in weaning diets. Mothers may also withhold food from infants who are ill in some Egyptian communities because of cultural practices, despite the fact that sick children are in great need of adequate nutrition. Gender of infants may also be an important factor, with male babies often receiving greater amounts of food than girls in Iran and other Middle Eastern countries.
| Summary|| |
In conclusion, then, a great deal of diversity exists in infant feeding patterns throughout the Middle East. This diversity is becoming even more pronounced due to the industrialization and economic development occurring in the region, and the impact they have on traditional gender roles, rural-to-urban migration, and market structures. Physicians, nurses, and other health care professionals must take into consideration the wide diversity in cultures, languages, ethnic groups, social practices, and religions found throughout the Middle East, and the profound level of change these factors are experiencing with the close of the decade. As such, programming strategies to encourage appropriate child feeding practices that are targeted for one community may not be appropriate for another in the region. The promotion of appropriate infant feeding practices in the Middle East, today must also be integrated as a key component of all primary health care and maternal-child nutrition programs developed in the region, in order to be truly effective. By incorporating such programs into overall health and development efforts, the well-being of the youngest and most vulnerable residents of the Middle East can be ensured for the 21st century.
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Department of Community Health Sciences, UCLA School of Public Health, L.A. California
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2]