Introduction: · Web viewDairy products, dark green vegetables, orange / red fruits and vegetables Good intake of dairy products, variable intake of vegetables / fruit Moderate night

Infant Feeding and Weaning Report 19-May-23

Infant Feeding and Weaning Report

Kosovo

January 2000

Action Against Hunger, UK.

Laura Phelps - Nutrition Co-Ordinator - Action Against Hunger UKJacqueline Conduah Birt - Nutritionist - Action Against Hunger UK

- 1 - Action Against Hunger – Kosovo


ACKNOWLEDGEMENTS

These reports were undertaken with the financial assistance of ECHO

To everyone who contributed to this survey, Action Against Hunger - UK is grateful; A special thanks to Dr. Monica Paslaru from UNICEF, Dr. Helene Lefevre-Cholay from

WHO, and Annnalies Borrel from UNHCR.

Sincere appreciation is given for all the hard work and sensitivity invested by the data collection teams, drivers and for the accurate data entry.

A special thanks should go to the mothers and children who participated in the collection of the data, without whom the survey would not have been possible.



Executive Summary

Important factors concerning childhood mortality and morbidity rates in any society are breast-feeding rates and infant feeding habits of the population. Our last breast / infant feeding survey conducted in July 1999, provided baseline data about the situation here in Kosovo. The picture suggested that breast & infant feeding practices could be significantly improved upon. However, it left some questions unanswered which have now been addressed 6 months on, and will allow us to prepare recommendations for incorporation into education for the evolving health system.

This survey was conducted as a complementary component of the most recent Nutritional Anthropometric1 and Food Security survey2. by Action Against Hunger – UK between the 12th

and the 22nd of January 2000, throughout the whole of Kosovo.

Objectives:

To provide an assessment of the current and retrospective breast / infant feeding practices (including the use of infant formula or other alternatives) in children 0-18 months. Identify the perceptions of mothers about the relative importance of breast / infant

feeding. Identify the main sources of information regarding breast / infant feeding. Identify the constraints and beliefs surrounding breast / infant feeding practice. Investigate the micronutrient content of infant’s diets. Determine the current practices for feeding a sick child. Provide further information regarding breast-feeding / infant feeding practices to allow

policy development. Determine the main messages needed for long-term education programmes.

Methodology:A random 30 x 30 cluster survey was undertaken. The population figures were obtained from the 1991 Kosovo population projection and the proportion of under five year olds was considered to be 12 % of the population. In order to achieve a 95 % CI, a total of 30 clusters with at least 5 children aged 0-18 months, and their mothers were required.

The survey comprised of two parts:1. A breast feeding / infant feeding questionnaire (quantitative & qualitative information) and2. A key informant discussion (information)

Data analyses:

Data processing and analyses was carried out using the EPI-INFO 5.0 software programme. Graphical representations of the data were formed in “Microsoft Excel”. 203 children between 0 and 18 months were included in the analysis of the survey for breast feeding & infant feeding practices. Questions asked were of current and retrospective practices.

The summary is a brief overview of the many important points discussed in the report.

Breast feeding practice

1 Action Against Hunger, Anthropometric Nutrition Survey, Kosovo 12th-22nd January 2000.2 Action Against Hunger, Food Security Survey, Kosovo, January 2000.



92 % of infants are initially breast-fed, however only 43 % of 0-6 month olds are exclusively breast fed. By 6 months 25 % of mothers have stopped breast-feeding. UNICEF & WHO recommend 100% exclusive feeding (no other foods or fluids) until 6 months of age and to continue breast-feeding until at least 1 year, preferably 2 years. A majority of mothers (57%) stop due to a perceived lack of milk, but as 57% of the infants receive other drinks (water, juice, tea – flower & Russian, cows milk) the breast will be under-stimulated by the full child. Drinks are mainly given via a bottle (61 %). Bottles are associated with a higher incidence of diarrhoea, which has been reported at 34 %3 in the under 5 years age group.

Treatment of diarrhoeaThere are no standard practices in treating diarrhoea and the same foods may be increased or decreased as treatment. Fluids were increased in some cases (juice, tea or soup) but it was not common practice. Health education including the importance of fluid and ORS and the potential effect of Russian tea is needed to reduce the incidence of diarrhoea.

Main sources of advice about breast feeding / infant feeding practiceWhen we looked at who provided the mothers with advice (Figure 11), it would appear that the mother followed by the mother in law and the doctor are the most influential in terms of practice in the community. However 93.5 % of mothers visited the doctor if they had problems or difficulties with breast-feeding. This has implications for current planned education programs as in order to reach all of the community it is clearly necessary to educate both mothers and doctors / nurses.

Infants receiving infant formulaThe predominant source of nutrition for infants who did not receive breast milk was self-reported as family food and cows milk. 15.9 % of mothers reported using infant formula, and of these only 35 % of the infants received the correct volume of formula for their age. This is very worrying as an inadequate amount could mean that the child does not receive enough energy, protein and micronutrients from the formula, ultimately impacting on their growth

Complementary foodsThe results of a 24 hour recall showed that 88 % of the children 0-18 months old were had eaten complementary foods in the previous 24 hours. 67 –73 % had eaten bread and cakes, 2 – 50.5 % fruit and vegetables, 18 – 35 % protein foods, and 1-20 % traditional Kosovar foods. This raises concerns for micronutrient intake. All of the mothers thought that complementary food introduction should begin at 2-3 months and that by the age of 6 months family foods should be introduced.

Conclusions and recommendations

Weaning practices Kosovo wide do not follow internationally accepted recommendations. They are potentially contributing to the relatively high incidence of chronic malnutrition (7.1 % 6-17 months old4) diarrhoea (34 %5) and iron deficiency anaemia and dental caries in children under 2 years of age. With widespread education and a clear message from health professionals, these negative practices could be significantly improved upon. In our experience mothers are very 3 IRC, IPH - Pristina, WHO, CDC. Kosovar Albanian Health Survey Report, September 1999. Prepared by Spiegal, P., & Salama, P., International Emergencies & Refugee Health branch, Centers for Disease Control & Prevention, Atlanta, USA.4 See footnote 15 See footnote 3



receptive to advice regarding their children, especially when the health implications are explained. National doctors and nurses are similarly interested in up-dating their knowledge. Similarly breast feeding practice is not receiving the necessary education and support for health professionals/mothers to encourage sustained exclusive breast feeding and to prevent further unnecessary use of alternative infant feeding products. This is the time for action concerning infant feeding and weaning practices in Kosovo.

In order to promote and protect breast-feeding and infant feeding practice in Kosovo the following recommendations should be acted upon.

1. Clear up to date education about good breast-feeding and infant feeding practices to the following groups; Mothers In hospitals to key staff dealing with infants in the hospital. In particular the neonatal,

gynaecology, maternity, and paediatric wards should be targeted. Ideally this should be carried out by the UNICEF Baby Friendly Hospital Initiative.

All health professionals involved with infants and pregnant/ lactating mothers. International expatriate staff dealing with infants and pregnant/lactating mothers, both

directly and indirectly. All international and national humanitarian organisations involved both directly and

indirectly in the distribution of food and specialist infant weaning products. All health professional at the faculty level.

3. All handling and utilisation of Breast Milk Substitutes should follow the UNMiK working document titled "Joint UN agency statement on donations of breast milk substitutes".

4. Development of nationally accepted guidelines endorsed by WHO for vitamin and mineral supplementation or, especially in relation to Iron, Folic Acid and Vitamins A, C and D.

5. Breast feeding education should concentrate on the following messages; Exclusive breast feeding, to ensure other drinks and foods are not introduced before 4-6

months of age Breast milk supplies protective immunoglobins, which protect against infections such

as, enter colitis, unlike infant formula Breast milk is free, the correct temperature and always available, whereas infant

formula is expensive and associated with a higher risk of infection for the child. Cows milk is for calves! What foods and drinks should be introduced and when

6. The indicated micronutrient problem should be further investigated using biochemical indicators to assess the extent of the problem. This should concentrate on:

Iron deficiency anaemia Neural tube defects (Folic Acid) Rickets Vitamin A deficiency



ContentsPREFACE.......................................................................................................................................................7

ACTION AGAINST HUNGER ACTIVITIES IN THE REGION – PAST AND PRESENT................8

1.0 INTRODUCTION.........................................................................................................................10

FIGURE 1...................................................................................................................................................12

2.0 INFANT FEEDING SURVEY BACKGROUND........................................................................14

4.0 METHODOLOGY.........................................................................................................................15

4.1 SURVEY DESIGN:....................................................................................................................154.2 SAMPLING METHODOLOGY:................................................................................................154.3 KEY INFORMANT DISCUSSIONS:.........................................................................................164.4 DATA COLLECTION FOR THE QUESTIONNAIRE:..............................................................164.5 DATA ANALYSES:...................................................................................................................16

5.0 RESULTS........................................................................................................................................17

5.1 BACKGROUND TO THE SURVEY POPULATION................................................................175.2 BREAST FEEDING.........................................................................................................................18

5.2.1 Current and retrospective breast feeding practice.................................................................185.2.2 Cessation of breast feeding and the reasons given.................................................................205.2.3 Introduction of foods and fluids into the diet..........................................................................215.2.4 Main sources of advice received by mothers..........................................................................27

5.3 NON BREAST-FEEDERS.........................................................................................................295.4 SUMMARY OF RESULTS.........................................................................................................31

6.0 DISCUSSION.................................................................................................................................33

7.0 CONCLUSION...............................................................................................................................36

8.0 RECOMMENDATIONS...............................................................................................................38

9.0 SOME USEFUL PUBLICATIONS AND CONTACTS.............................................................39

ANNEXES.....................................................................................................................................................41

ANNEXE 1: MAP OF KOSOVO BY MUNICIPALITY -SEE ANTHROPOMETRIC REPORT ANNEXE 1*.....................................................................................................................41

ANNEXE 2: CLUSTER ALLOCATION BY MUNICIPALITY - SEE ANTHROPOMETRIC REPORT ANNEXE 3*.....................................................................................................41

ANNEXE 3: CHANGES TO ORIGINAL CLUSTER ALLOCATION - SEE ANTHROPOMETRIC REPORT ANNEXE 4*.....................................................................................................41

ANNEXE 5 BREAST FEEDING / INFANT FEEDING QUESTIONNAIRE................................................43ANNEXE 6 KEY INFORMANT SITES...............................................................................................49ANNEXE 7 KEY INFORMANT DISCUSSION GUIDELINE...................................................................50ANNEXE 8 APPROVED SELECTION CRITERIA FOR THE DISTRIBUTION OF HUMANITARIAN FOOD AID

IN KOSOVO.........................................................................................................................52ANNEXE 9 UN CIVIL ADMINISTRATION............................................................................................53Annexe 10 Use of breast milk substitutes.......................................................................................54



Preface

This report is a direct result of the experiences of Action Against Hunger - UK personnel operating in the Balkans before, during and after the Kosovo crisis. It brings together qualitative and quantitative information collected recently on infant nutrition and weaning practices within Kosovo6.

The attitudes and actions, both direct and indirect, of health policy makers and humanitarian organisations (national and international) continue to have a direct impact on infant feeding and weaning practices of the Kosovo people, in this transition phase.

Unsustainable actions by humanitarian organisations, combined with the opportunistic marketing by international conglomerates could, over time, influence the choice of the population towards breast milk substitutes and prepared complimentary foods over breast feeding and home prepared complimentary foods.

The aim of this report is to inform and direct health policy makers, national and international humanitarian organisations towards the protection and promotion of breast-feeding and good infant feeding practices, specifically in Kosovo.

The onus is on the international community to act responsibly towards all aspects of infant nutrition and feeding in Kosovo.

It is hoped that as a result of this and other reports, national and international organisations will take their own lead in shaping policy and increasing the knowledge within their own organisation and staff.

This report is designed to be read, in conjunction with the July 1999 breast feeding/infant feeding report7, so as not to repeat ideal practice or previous recommendations. This report is available in the Action Against Hunger offices, Pristine.

6 This survey was Kosovo wide. A majority of those surveyed were Albanian, but also included Serbian, Roma and Goran families. This data does not provide a distinction between the two groups.7 Action Against Hunger – UK, Infant feeding and weaning survey, Kosovo. 15-27 July 1999.



Action Against Hunger activities in the region – past and present

The Action Against Hunger International Network is a private, non-governmental, voluntary, non-confessional, non-profitable and non-political organisation. It was created in 1979 in France and now has Head Offices in Paris (ACF-France), Madrid (ACH-Spain), London (AAH-UK) and New York (AAH-USA). It operates in more than 30 countries in Africa, Asia, Central and South America and in Eastern Europe. Its purpose is to fight hunger through its expertise in nutrition, food security, water/sanitation and primary health care.

Action Against Hunger - UK has been operating in Kosovo since October 1998. Action Against Hunger - UK first conducted a nutrition and food security survey, including a study of agriculture throughout Kosovo. AAH then distributed seeds and tools to 5,100 families in Kline, Rahovac, Suhareka and Malisheve Municipalities in February/March 1999.

AAH evacuated to Macedonia in March 1999, where we carried out fresh food complementary distributions to 35.000 refugees in host families in the South, together with a collective kitchen of 3,500 meals per day in Gostivar. AAH was also designated Camp Manager of Blace Transit Camp at the Macedonia/Kosovo border.

Action Against Hunger USA and Action Contre la Faim France have been operating in Albania and Montenegro during and since the conflict. Action Against Hunger –UK returned to Kosovo on the 13th of June 1999. Current activities of the organisation are detailed below:

General Distribution

AAH is an implementing partner of UNHCR /WFP and is responsible for the targeted general food and non-food item distribution to approximately 180,000 beneficiaries in Pristine town, Podujevo and Gllogovc municipalities. Food and non-food items are provided by WFP and UNHCR. In July 1999 AAH conducted a Kosovo-wide food security survey, this has been repeated in January 2000.

Agriculture

AAH completed a programme of winter wheat seeds distribution, including fertilisers and seed drills, in Gllogovc, Rahovac, and Suha Reka municipalities. It covered approximately 12.500 families. Another large-scale distribution of seeds and tools has been undertaken for this April in Gllogovc and Skenderaj municipalities assisting approximately 10,080 families. A distribution of supplementary cattle feed was carried out in Skenderaj municipality during February / March 2000.



Nutrition

AAH has also conducted a Kosovo wide nutritional status and breast-feeding practises survey in July 1999- report available in AAH office. A further Kosovo-wide nutrition / infant feeding survey has been undertaken in January 2000, and the report available in March. These reports highlight the common practices in breast-feeding / infant feeding in Kosovo and have led us to undertake an education programme highlighted below.

AAH set up a mobile nutrition screening team, in coordination with mobile clinics, in order to provide basic training to health workers, and to refer malnourished persons identified to hospital. AAH is also working on therapeutic feeding in Pristine hospital, and has set up a referral system to Peja and Prizren hospitals.

AAH is currently concentrating on a 15 municipality wide education programme to increase awareness and improve practice surrounding issues of breast feeding, infant feeding and growth monitoring in secondary / primary health care structures and at the ground level with women's groups. The municipalities included in this programme include; Podejevo/Podujevo, Prishtine/Pristina, Vushtrri/Vucitrn, Fushe Kosove/Kosovo Polje, Gllogovc/Glogovac, Skenderaj/Srbica, Istog/Istok, Kline/Klina, Peje/Pec, Gjakove/Djakovica, Rahovec/Orahovac, Malisheve, Suhareke/Suva Reka, Shtime/Shtimle and Prizren. This education programme is in line with the WHO family medicine module, which will be introduced to all the doctors in Kosovo, starting in June; and is in collaboration with IPH and UNICEF. AAH is also involved in an infant feeding practices training for health workers in health structures Kosovo wide in collaboration with UNICEF, WHO and IPH.

Water

AAH is completing an emergency operation of well cleaning and chlorination in Podujevo and Pristine municipalities. To date more than 1,000 wells have been cleaned. AAH has also distributed a total of 5,100 electric water pumps to vulnerable households in five municipalities and is presently extending this activity to an additional Municipality. AAH is also assisting two schools in Podujevo (Lluzhan and Orllan) with water and sanitation provision. AAH is also protecting 120 wells in 41 villages in Podujevo.

ECHO, UNHCR, DfID, GAA and OFDA fund AAH in Kosovo.AAH in Kosovo is a team of 12 international and 90 national staff.



1.0 Introduction.

Kosovo is the southern Province of the Federal Republic of Yugoslavia (FRY). The average per capita income was approximately $470 in 1991 and up to 50 % unemployment8. It covers a geographical area of 10, 887 m2, with a population density of 200 persons per square kilometre, which is one of the highest densities in Europe. There was little accurate epidemiological data kept on the Albanian population in the 10 years prior to the conflict as they utilised the parallel health system provided by the NGO Mother Theresa Society (MTS). The pre-conflict birth rate of 21.6 per 1000 inhabitants, and an infant mortality rate of 23.6 per 1000 live births9 were amongst the highest in Europe. According to pre-conflict sources in the parallel health system, these rates are up to twice as high in some areas of Kosovo10.

In 1997 the UNICEF MICS11 survey showed that only 12.2 % of the children were exclusively breast fed until 4 months. Prior to the conflict a reported 76.8 % of children breast fed for more than 3 weeks while post conflict12 71.5 % were reported to breast feed for more than 3 weeks. The July 1999 report also highlighted the high number of women (44 %) who reported stopping breast feeding due to insufficient milk13.

A recent report led by Centres of Disease Control, Atlanta, looked at epidemiology in the Albanian population14. Although these figures do not represent the different ethnic groups, they are still very important. The epidemiological profile in this population is one of a developed country with low mortality rates and a high prevalence of non-communicable diseases. They also saw that preventative measures such as public health education and immunization services have suffered during the chronic conflict, with poor immunization coverage and inadequate maternal knowledge of the correct management of diarrhoea. The mean age of the population is 26.4, sex ratio 1.10:1.00 and an average of 9.2people per dwelling. A total of 12 % of household are currently displaced. The under 5 year olds make up 10 % of the population.

The CDC report found that in children ≤ 6 months that 64 % were currently being breast-fed, 20 % received infant formula and 10 % cows milk. Interestingly children under 2 years in urban areas were more likely to receive infant formula, than those in rural areas. When compared to other countries in Europe these figures are high, suggesting that the use of infant formula requires attention.

8 See footnote 39 Institute of Public Health Federal Republic of Yugoslavia. (Belgrade 1997).Health Statistical Yearbook 1996.10 Dedushaj. I. (Pristina 1997). Epidemiologjia p.20.11Federal Republic of Yugoslavia, Institute of Public Health of Serbia and Montenegro. (Belgrade 1997). UNICEF Multiple Indicator Cluster Survey.12 See footnote 1113 See footnote 1114 See footnote 7



They reported a prevalence of 32 % for ARI and 34 % for diarrhoea (24 % for urban areas and 36 % for rural areas). Diarrhoea was associated with lack of access to piped water. Over half of the mothers reported stopping breast feeding as part of the treatment for diarrhoea, with only 27.3 % continuing to breast feed and 10 % who did not know what action to take.

Of those seeking healthcare 28 % were under 5 years of age, with 73 % of the expenditure on healthcare going on medications (a potential 97.5 Deutche Marks per individual per year). This does not necessarily include the hidden costs incurred in the evolving "nominally free" health care system.

Important factors concerning child mortality and morbidity rates in any society are breast-feeding rates and infant feeding habits of the population. It has been reported that in the Balkans, and particularly among the ethnic Albanian population that infant feeding and weaning practices could be significantly improved15. Although breast-feeding is an integral part of Kosovar culture, early or late weaning on to nutritionally inadequate foods has a detrimental effect on the nutritional status of the children. These habits have been exacerbated by several factors, including the reduction in household food security due to the chronic conflict and destruction in the region.

Post conflict the perceptions of the mothers towards their ability to feed their children was often poor, with many women believing that the quality or quantity of their breast milk was inadequate. This has been compounded by distributions of infant formula by humanitarian organisations, who have played a strong role in the undermining of breast feeding promotion, as outlined in a recent report16.

Figure 1 summarises internationally recognised good infant feeding practices for the introduction of food into the diet. This is important to refer to when looking at the results of the survey.

15 Federal Republic of Yugoslavia, Institute of Public Health of Serbia and Montenegro. (Belgrade 1997). UNICEF Multiple Indicator Cluster Survey.16 Forsythe.V., WHO consultant, July 1999. Report of WHO Infant Feeding Consultancy to the Former Yugoslav Republic of Macedonia and Albania.



Figure 1

Summary of Recommended Feeding and Dietary Practices - WHO 1999

Infants 0 to 6 months

Initiate breastfeeding within about one hour of birth

Establish good breastfeeding skills (good positioning and attachment).- Baby should be held close to mother, facing the breast, with the

baby’s ear, shoulder, and hip in a straight line.- Infant’s mouth should open wide just before attaching so the nipple, and as much

of the areola as possible, are in the mouth. - If properly attached, the lips are rolled outward, with the tongue over the lower gum.- Signs of effective feeding include visible jaw movement drawing milk out,

rhythmical suckling with an audible swallow, and no drawing in of cheeks.

Breastfeed exclusively (no prelacteal feeds, no other foods, no water or other liquids) for about the first six months.

Practice frequent, on-demand feeding, including night feeds (8-12 breastfeeds per 24 hours, every 2-3 hours, or more frequently if needed).

In areas where vitamin A deficiency occurs, mother should take a high dose vitamin A supplement (200,000 IU) as soon as possible after delivery, but no later than eight weeks postpartum, to ensure adequate vitamin A content in breast milk.

Breast fed children 6 to 24 months

Continue frequent, on-demand breastfeeding, to 24 months and beyond.

Introduce complementary foods beginning around six months of age.- Breastfeed before each feeding of complementary food.

Increase food quantity as the child ages while maintaining frequent breast-feeding.- Provide 6 - to 8- month-old infants approximately 280 kcal per day from

complementary foods.- Provide 9- to 11 month - old infants approximately 280 kcal per day from

complementary foods.- Provide 12- to 24- month-old children approximately 750 kcal per day from

complementary.- Increase complementary feeding frequency as the child ages, using a combination

of meals and snacks.- Feed complementary foods to 6- to 8- month-old infant 2-3 times per day.- Feed complementary foods to 9- to 11- month-old infant 3-4 times per day.- Feed complementary foods to 12- to 24- month-old children 4-5 times per day.



Gradually increase food thickness and add variety as the child ages, adapting the diet to the child’s requirements and abilities.

- Feed mashed and semi-solid foods to infants, starting around 6 month of age.- Feed energy-dense combinations of foods to 6- to 11-month-olds.- Introduce “finger foods” (snacks that can be eaten by children alone) at about 8

month of age.- Make the transition to the family diet at about 12 months of age.

Diversify the diet of both the breastfeeding mother and the child by including fruits, vegetables, fortified foods, and/or animal products to improve quality.

- Feed fruits and vegetables daily, especially those rich in vitamin A and other vitamins.

- Feed meat, poultry, fish, or other animal products daily or as often as possible (if feasible and acceptable).

- Use fortified foods, such as iodised salt, vitamin A-enriched sugar, iron-enriched flour, or other staples, when available.

Practice active feeding.- Feed infants directly and assist older children when they feed themselves.- Offer favourite foods and encourage children to eat when they lose interest or

have depressed appetites.- If children refuse many foods, experiment with different food combinations,

tastes, textures, and methods for encouragement.- Talk to children during feeding.- Feed slowly and patiently and minimize distractions during meals.- Do not force children to eat.

Practice frequent and active feeding during and after illness.- During illness, increase fluid intake by more frequent breastfeeding, and patiently

encourage children to eat favourite foods.- After illness, breastfeed and give food more often than usual, and encourage

children to eat more food at each sitting.

Practice good hygiene and proper food handling.- Wash caregivers and children’s hands before food preparation and eating.- Keep all food preparation surfaces clean; use clean utensils to prepare and serve

foods.- Cook food thoroughly.- Avoid contact between raw foodstuffs and cooked foods.- Serve foods immediately after preparation; avoid storing cooked food.- Wash fruits and vegetables.- Use safe water.- Use clean cups and bowls; never use feeding bottles.- Protect foods from insects, rodents, and other animals.- Store non-perishable foodstuffs in a safe place (separate from pesticides,

disinfecting agents, or other toxic chemicals).



2.0 Infant Feeding Survey Background

Our last breast / infant feeding survey conducted in July 1999, provided baseline data about the situation here in Kosovo. However, it left some questions unanswered which have now been addressed 6 months on, in January 2000.

The infant feeding and weaning survey was conducted as a complementary component of the most recent Nutritional Anthropometric17 and Food Security survey18. It was considered very important in light of the developing health care structure and as a follow up to our of reported infant feeding practices. The breast feeding and infant feeding survey will allow us to establish a clear picture of the present situation 8 months post conflict in order to develop suitable recommendations for the future. These will be important to prepare recommendations for incorporation into education for the evolving health system.

Objectives:

Provide an assessment of the current and retrospective breast / infant feeding practices (including the use of infant formula or other alternatives) in children 0-18 months.

Identify the perceptions of mothers about the relative importance of breast / infant feeding.

Identify the main sources of information regarding breast / infant feeding.

Identify the constraints and beliefs surrounding breast / infant feeding practice.

Investigate the micronutrient content of infant’s diets.

Determine the current practices for feeding an unwell child.

Provide further information regarding breast-feeding / infant feeding practices to allow policy development.

Determine the main messages needed for long-term education programmes.

Note:

The word infant refers to all children less than 12 months of age and Young children refers to children less than 5 years of age.

17 Action Against Hunger, Anthropometric Nutrition Survey, Kosovo 12th-22nd January 2000.18 Action Against Hunger, Food Security Survey, Kosovo, January 2000.



4.0 Methodology

4.1 Survey Design:

A random sampling two-stage cluster survey was calculated using Epi Info Statcalc version 6.04b19. The target number of individuals primarily calculated to achieve a 95 % confidence interval (95 % CI) at +/- 0.5% around an estimated frequency of breast / infant feeding problems of 90 % was 138. In order to achieve a 95 % CI, a total of 30 clusters with at least 5 children aged 0-18 months, and their mothers were required. This will provide a valid picture of the infant feeding and weaning trends in Kosovo.

4.2 Sampling Methodology:

The population figures used were obtained from the 1991 Kosovo population census and the proportion of under five year olds was considered to be 12% of the population (estimated using data from December 1998 survey)20. The cumulative population of children under 5 was calculated and the sampling interval was determined. From this the cluster allocation for each municipality was drawn (Annexe 1, 2 & 3). The random cluster selection was achieved by treating every village/town district as a potential cluster. Then random number tables to allocate the cluster.

Within each cluster the centre was ascertained from the local population. A random starting point was selected by spinning a pen to determine the direction of travel. Then the number of total dwellings in one direction was counted up to the end of the village, and a house was randomly selected in this direction. Subsequent households were selected as the nearest dwelling to the left from the door of the compound or dwelling. If there was more than one dwelling in the compound the dwelling to the direct left of the entrance was chosen.

Only one child from 0-18 months was chosen randomly from the family. If the child was not present then the team made an appointment to return in order to question the mother. If the child’s natural mother was not present, the team returned at a set time. If the mother was still not there then the main female carer of the child was questioned in place of the mother. If the child did not have a biological mother, then the main female carer in the household was chosen.

The variables regarding breast-feeding and infant feeding are identified in the questionnaire: Annexe 5.

19 Dean, A. G., Dean, J.A.D.C., et al. Epi Info, Version 6: a word processing database and statistics programme for epidemiology on microcomputers. Atlanta, Georgia, U.S.A.; Centers for Disease Control and Prevention, 1994.20 Action Against Hunger, Mercy Corps International, UNICEF, (December 1998) Nutritional Anthropometric, Child Health and Food security survey. Kosovo, FR Yugoslavia.



4.3 Key informant discussions:

Additional data in the form of key informant discussions was collected in 3 of 21sites (see Annexe 6). These discussions were carried out by the food security teams due to their experience in key informant discussions. More sites were planned but time constraints limited the total number. The key informant discussions were held with groups of women from different age groups. Each group contained at least one young mother, a middle aged mother and a grandmother. Two trained monitors conducted these discussions using guidelines of subjects to discuss (see Annexe 7). These discussions were intended to provide information to fill in the gaps in knowledge about infant feeding and weaning practices in Kosovo.

4.4 Data collection for the questionnaire:

In total six teams were used to collect the data. Each team comprised of 3 monitors (1 male and 2 females - Annexe 4). The females were responsible for asking the questionnaire, as it was not deemed appropriate for the males to ask about breast-feeding. The nutritionists at Action Against Hunger undertook the monitors training. They were trained over 4 days in all aspects of questionnaires including sampling methodology, questionnaires, field-testing and security. The final day of the training consisted of the practice of a test cluster, performed in teams. The survey was completed between the 12th and the 22nd January 2000.

4.5 Data analyses:

Data processing and analyses was carried out using the EPI-INFO 5.0 software programme. Graphical representations of the data were formed in “Microsoft Excel”. A total of 207 records were analysed for the breast-feeding results and infant feeding results.



5.0 Results

5.1 Background to the survey population

Data was collected on 203 children between 0-18 months. A total of 32.2 % of those surveyed lived in an urban environment, and 67.8 % in a rural setting; of these 43.4 % lived in destroyed dwellings.Table 1 defines the humanitarian food aid selection criteria that the families fell into:

Selection criteria summary (Annexe 8)

n %

1 - destroyed house 17 8.22 - Internally displaced

person / host family for IDP's25 11.9

3 - Families permanently unable to generate income

2 0.9

4.1 - social case 17 8.24.2 - social case 12 5.74.3 - social case 3 1.54.4 - social case 14 6.7

No criteria 117 56.9TOTAL 207 100

Table 1: Humanitarian food aid selection criteria for the survey population.

Categories are clearly defined in Annexe 8. Nearly 12 % of those questioned reported being displaced which could have a significant impact on "normal" practices. Only a low number (0.9 %) reported being permanently unable to generate income, and a further 22% were social cases. These families, which are more likely to be vulnerable to malnutrition due the many factors affecting their economic recovery and food security. It may well be that a certain percentage of these social cases were vulnerable before the conflict, and may continue to struggle now. It is worrying that 8.2 % of these social cases were single parent households, as this factor alone is recognised as contributing negatively to nutritional status.

The sex ratio is 0.96 (48.9 % females to 51.0 % males). The mothers mean age is 27.8 years (minimum 18 years, maximum 44 years). Figure 2 shows the age sex pyramid of the sample population.



Figure 2 Age Sex pyramid of the sample population

5.2 Breast Feeding

5.2.1 Current and retrospective breast feeding practice

Figure 3 shows the breakdown of the current status of breast-feeding. 7.7 % of infants have never received breast milk; this figure is lower than in July 1999 when it was reported to be 11 %. This incidence of breast-feeding is comparable with other areas in the region. For example the 1999 multiple indicator cluster survey conducted in Macedonia by UNICEF21 reported an breast feeding incidence of 92%; with 8% not breast feeding.

Figure 3 Current breast-feeding status

21 UNICEF, Multiple indicator cluster survey in FRYROM with micronutrient component, November 1999.



Figures 4 shows the type of breast-feeding that the child currently receives. A total of 20% (all age groups) reported exclusively breast-feeding22, and 43% of the 0-6 month olds. In 1997 the UNICEF MICS23 survey showed that only 12.2 % of children were breast-fed exclusively until 4 months. More recently the combined Nutritional Anthropometric, Child Health and Food Security Survey in 1998 showed that 25.6% of mothers do not continue breast feeding past 3 months24. This downward trend may have been exacerbated by the conflict. For example, 23% of infants under 4 months in refugee camps, Macedonia, did not receive breast milk or a suitable breast milk substitute25.The authors feel that this figure is too high when compared to observed practices in Kosovo. This high rate of exclusive breast-feeding is likely to be due to the mothers misunderstanding of the definition of exclusive breast-feeding; especially as they reported that over half of infants 0-6 months of age receive foods and drinks as well as breast milk. This displacement of breast milk by other foods and fluids can have serious implications for the nutritional status of the child. WHO/UNICEF recommend that mothers exclusively breast feed until around 6 months.

Figure 4 Exclusive, predominant and mixed breast-feeding in children 0-6 months of age

Exclusive breast-feeding is used when all fluid, energy, and nutrients are provided by breast milk, with the possible exception of small amounts of medical supplements. Predominant breast-feeding refers to the use of only water or other non-nutritive liquids in addition to otherwise exclusive breast-feeding. Mixed breast-feeding is used to indicate mixed feeding with breast milk and other sources of energy and nutrients.

The July 1999 survey results documented the fact that a majority of mothers feed on demand (n = 678, 93.5 %) and this trend followed for feeding at night (n= 701, 96.4 %) with a total of 35% of mothers who reported stopping breast feeding ≤ 6 months.

22

23 Federal Republic of Yugoslavia, Institute of Public Health of Serbia and Montenegro. (Belgrade 1997). UNICEF Multiple Indicator Cluster Survey.24 Action Against Hunger, Mercy Corps International, UNICEF (December 1998) Nutritional Anthropometric, Child Health and Food Security Survey. Kosovo, FR Yugoslavia.25 UNHCR, Action Against Hunger, Macedonian IMCH, UNICEF (June 1999)Nutrition and Health Survey of Kosovar Refugees in camps in Macedonia.



Figure 5 represents the importance placed on breast-feeding by mothers. It is scaled from 1 to 5 with 5 being "very important".

Figure 5 Relative importance of breast-feeding as reported by the mother

It is very clear from this pie chart that breast feeding is highly valued, as 83% of mothers rated it 5. None of the mothers rated breast-feeding as 1, which was not at all important. This is a very good indicator of intended practice, however by 6 months of age 25% had stopped breast-feeding their child.

5.2.2 Cessation of breast feeding and the reasons given

Figure 6 shows when the mothers questioned stopped all types of breast-feeding. A total of 24.8 % reported stopping breast-feeding by 6 months of age. (It must be noted that 55% of the mothers questioned were still feeding and so they could not be included in this table).

Figure 6 Age at which breast-feeding was discontinued

Reasons why mothers stopped breast-feeding varied (Figure 7) but were predominantly due to a self reported lack of milk (57 %). This is a very common reported problem in Kosovo.



Figure 7 Reasons for cessation of breast-feeding

Mothers were asked to compare breast milk, infant formula, cows milk and tea with sugar as the most suitable nutrition for their infant. Breast milk was given priority, followed by infant formula and cows milk - depending on the availability and finally tea with sugar.

5.2.3 Introduction of foods and fluids into the diet

Figure 8 shows the fluids, which are given to the infant in the 24 hours prior to the survey.

Figure 8 Drinks taken in the last 24 hours by breast-feeding childrenThese drinks are predominantly given via the bottle (60.6%), which not only has a potentially detrimental effect on the incidence of dental caries and is associated with up



to five field increase in incidence of diarrhoea26 in infants when compared to breast-feeding.

Figure 9 looks at the foods, which would be administered and excluded from the diet of a sick infant. It can be seen that for certain items including biscuits, cows milk, soup, breast milk, tea, and juice that they are either given or excluded according to the individual family practice.

Figure 9 Foods given or excluded from the diet of a sick child

More specifically Figure 10 looks at the drinks given to infants who have diarrhoea and whether they are increased, decreased remain the same or are removed from the diet. It would appear that both breast milk and flower teas are increased if the infant has diarrhoea, and that Russian tea and cows milk are reduced.

The July 1999 survey showed that the mean time for introduction of cow’s milk is 5.4 months (SD 3.5) for children 6-18 months. 97% of children received cows milk before 1 year of age (68% before 6 months) on a daily basis.

26 Howie, P. W., Forsyth, J. S., Ogston, S.,A. et al. Protective effect of breast-feeding against infection. BMJ, vol 300, no 6716, 6 Jan 1990, pp 11-16.



Figure 10 Drinks given to children with diarrhoea

The results of a 24-hour dietary recall showed that 178 out of 203 children were eating complementary foods. When asked about the previous day 34% were not currently eating a normal diet due to illness (22%), access to food (1.6%) lack of money (1.6%) and other reasons (8%). Figure 11 shows the variation in the foods eaten by group and the range of intake.



Figure 11 Foods eaten by children in the last 24 hours (minimum and maximum intake per food group)27

It can be seen that bread and cakes make up the main part of the infants diet (67 –73 % reported intake in the last 24 hours). It is not surprising that the intake of bread is so high, as it the staple food in Kosovo. Its introduction is in fact not as early as the biscuit products and therefore not as detrimental.

Generally the intake of both fruit and vegetables is variable and for some children very low 2 – 50.5 % of children received fruit and vegetables in the last 24 hours). This does not follow complementary feeding guidelines. Fruits and vegetables provide important vitamin C, which helps assist the absorption of iron. All infants should eat fruit and vegetables on a daily basis from 6 months of age.

Eggs, meat, fish and beans intake varies between 18 – 35 % in the last 24 hours. This supports the reported low intake of iron rich foods in the diet. Diary products were received by less than a quarter of the children in the last 24 hours.

Other traditional foods such as Griz and the more modern fizzy drinks make up only a small part of most children’s diets (1-20 %). They provide good sources of energy in the form of fat and carbohydrate, but do not contribute significantly to the vitamins and minerals in the diet.

27 Flea – Flour, salt, water, sour cream, oil / margarineKacamak – Corn flour, water, salt, oilPite – Flour, salt, water, meat / spinichGriz – Corn flour / rice flour / flour, sugar, water



Table 2 summarises the micronutrients in the diet which are of concern and suggests possible actions

Micronutrients Sources in the diet

Average intake

Evidence of deficiency

Recommendedaction

Sodium Sodium chloride, snacks, cheese

Lots of salt is added to family foods

None National campaign to reduce salt intake in adults and children

Iron Meat, poulty eggs, spinach, cabbage (liver is generally not eaten by children)

Heam sources vary dependent on incomeNon heam sources are eaten in variable proportions

High incidence of moderate anaemia reported in children and mothers

National campaign required to highlight good sources of iron and vitamin C in the diet and promote these to infants, menstruating women and mothers

Iodine Poor soil content, iodised salt imported

High salt intake therefore high iodine intake

Occasional goitres diagnosed

Continue importing iodised salt

Vitamin A Dairy products, dark green vegetables, orange / red fruits and vegetables

Good intake of dairy products, variable intake of vegetables / fruit

Moderate night blindness reported in Macedonia28, no recent reports for Kosovo

Night blindess could be assessed to ascertain level in KosovoAnti oxidant effect could be promoted in relation to smoking / passive smoking

Vitamin D Egg, oil, margarine, butterSunlight

Variable depending often on family income and swaddling of infants

Reported incidence of rickets

National program to recommend that infants are not swaddled and that safe exposure 10-20 minutes of light per day National policy on vitamin supplementation

Vitamin C Fruits and vegetables

Variable intake due to income and low priority placed on intake

No frank scurvy reported, but occasionally attributed to high incidence of gum disease

National campaign to promote fruits and vegetables – importance of iron absorbtion and anti –oxidant effect

Micronutrients Sources in the diet

Average intake

Evidence of deficiency

Recommendedaction

Folic Acid Green leafy None Variable intake National folic Acid 28 UNICEF, Multiple indicator cluster survey in FRYROM with micronutrient component, November 1999.



vegetables, (nuts, liver – not given to young children) bananas

reported, but unchecked levels of neural tube defects in infants

campaign for supplementation in the first trimester of pregnancy

Table 3 outlines the mother’s knowledge and practice for introduction of complementary foods to infants at different stages. It is clear that common practice does not support exclusive breast-feeding until around 6 months.

Age Foods given2-3 months Biscuits, cows milk, flower tea, juices, Plazma biscuits, fruits4-5 months Eggs, potatoes, biscuits, pie, rice, soup, fruit, tea, water, cows milk, griz,

yogurt6-7 months Family food8-9 months Family food10-11 months Family food>11 months Family food

Table 3 Age at which mothers feel complementary foods should be introduced

When mothers were asked about the main causes of anaemia they stated the following; Incorrect foods Mother was sick (presumably at the birth of the child) Genetic causes Didn’t know

This suggests that there needs to be a clear information campaign regarding anaemia and good dietary sources of iron.

The main constraints identified to feeding the child normally included – availability of goods and inadequate finances to purchase goods. This was a strong re-occurring message from mothers who were keen to change practice but did not feel that they had the financial resources to do so. In many cases appropriate changes to the children’s diets could be made with little or no impact on finances following education programs.

5.2.4 Main sources of advice received by mothers

When we looked at who provided the mothers with advice (Figure 12), it would appear that the grand-mother followed by the mother in law and the doctor are the most influential in terms of practice in the community. However 93.5 % of mothers visited the doctor if they had problems or difficulties with breast-feeding. This has implications for current planned education programs as in order to reach all of the community it is clearly necessary to educate both mothers and doctors / nurses.



Figure 12 Main information sources for mothers regarding breast ./ infant feeding

5.3 Non Breast-Feeders

The predominant source of nutrition for infants who did not receive breast milk was self-reported as family food and cows milk. 15.9% of mothers reported using infant formula, and of these only 35% of the infants received the correct volume of formula for their age.

The UNICEF study carried out in Macedonia29 reported that a fifth of the infants were using infant formula. This is currently higher than in Kosovo.

Water sources for infants receiving infant formula

A trend for the water source for the infants receiving infant formula is outlined in Figure 13.

Figure 13 Main water sources for the sample population




These water sources are typical for Kosovo. Wells with buckets represent a higher risk of water source contamination than wells with pumps. Spring sources are generally safe but dependent on the transportation, and public water supplies are considered to be the safest source. Safety of water supply has obvious implications for the incidence of diarrhoea. The increased risk of infant formula prepared in a bottle with unclean water could be a contributor to this incidence in some children.

If infant formula is incorrectly prepared then there is an increased risk of diarrhoea, either due to un-clean water or due to incorrect dilution strength. It can be seen from the above results (Figure 9) that fluid treatment for diarrhoea varies, but Oral Rehydration Solution (ORS) is variable in its correct adequate use. Diarrhoea is a significant problem in Kosovo; the September 1999 CDC report found a 33.5% incidence of diarrhoea in children under 5 years of age.

Cost of infant formula to the family

For the families using infant formula they reported spending more than 100 DM per month, which is just less than the financial equivalent of the food aid (Equivalent to 110 DM). This is a significant amount of money, especially when it is considered that breast milk is free.

5.4 Summary of results

The following provides a summary of main trends in beliefs and practices from amongst those interviewed (questionnaire and focus-group discussions) within the survey

Importance of breast-feeding: Breast feeding is considered to be a very important food for the child containing all

the components necessary for growth, especially in the first 6 months of life Considered the best food for the child until 1 year as it contains all of the vitamins

necessary, after 1 year the child needs additional food One mother had been advised to avoid cows milk as the cows are eating rubbish post

conflict

Exclusive breast-feeding: This is supported as the best option, but it was felt that if breast milk was inadequate

that cows milk diluted with water should be given. It especially satisfies the baby and helps it to sleep

Order of importance of different breast milk substitutes: Breast-feeding is considered the best followed by cow’s milk (dilution with water

was stated as important to prevent sickness). Cows milk was thought to have more calories than breast milk Cows milk was felt to be preferential to infant formula



Who do they receive support from if they have problems with breast feeding: Paediatrician Grandmother Neighbours

What problems do they or have they had: Inadequate breast milk No problems - infant fed up until 2 years

If a child receives infant formula what are the main reasons: Mother is pregnant with a second child so breast feeding is ceased and replaced with

infant formula Would like to give child infant formula but the family cannot afford it Infant formula was felt to be inferior to breast milk and therefore was not used

At what age did they /should they introduce family foods: At 3 months the following were introduced - tea with lemon and sugar, wheat flour

and cows milk, cows milk and boiled rice with water. At 6 months the following were introduced - potatoes, beans and bread, biscuits and

cows milk, banana and juice, tea and sugar, soup and mashed potatoes, boiled vegetables, eggs

At 11/2 years of age the child should start to eat family food

What foods do they /did they give or exclude from the diet of a sick child (ths same foods were both given or excluded by different mothers in the same group: Rice water and sugar Bananas, biscuits and tea Fruits, biscuits and cows milk Different rehydration solutions were suggested but none matched the WHO

recommendations

Why do they think children become anaemic? Due to a lack of vitamins in the diet Because the children don't like to eat fruits, vegetables and because of a lack of cows

milk Due to a lack of fruits, vegetables, drinks and as a result of a poor appetite

Have their infant feeding and breast-feeding practices changed since the conflict: Less cows milk is available as the cows are lost Less money is available for food No changes were reported

What are the main constraints to feeding their children, as they would wish? Reduced income and availability of certain foodstuffs e.g. bananas and vegetables



6.0 Discussion

This summary is based on research, information from mothers in this survey and author observation.

Chronic MalnutritionResults from longitudinal growth studies and data from nutritional surveillance activities both indicate that growth stunting occurs within a fairly narrow "age window" from several months after birth to about 2 years of age30. This indicates the importance of breast and infant feeding during the early months of life and the hazards of introducing complementary food too soon. Consequently targeting programmes to this age group may be more cost effective than programmes that include a broader age range of children.

Anaemia, diarrhoea and dental cariesAnaemia has been highlighted as being a significant problem in mothers and children by practicing doctors in Kosovo, but there have been no recent studies to confirm the incidence. A recent survey in Macedonia31 looked at infant feeding practice and recorded the incidence of mild and moderate anaemia in mother and child. It was reported at 12% in mothers and 26% in the children 6-59 months of age. It could be expected that this rate would be similar or even higher here.

Previous research32 confirms that tea is commonly given to children from the age of 2-3 month, in bottles with 1-3 teaspoons of sugar. The poor accessibility of products with high iron bio-availability, such as meat (see table 3) in more vulnerable families may be compounded by the poly-phenol content of tea which is responsible for the inhibition of iron absorption.

In addition the added sugar is very bad for the development of the teeth and many children have resultant dental caries at a very young age. Lastly the caffeine content of the tea is not advisable in the diet of such young children and may contribute to an increased gut motility (contributing to any diarrhoea) and reduced absorption of nutrients.

The use of cows milk as a breast milk substitute, often undiluted, is a cause of microscopic intestinal blood loss which can lead to diarrhoea, and may be another explanation for the reportedly high incidence of anaemia.

Early introduction of complementary foodsExclusive breast-feeding is still insufficient, with less than a quarter of the children under 6 months receiving breast milk alone. This is due to the early introduction of teas, water, juice, cows milk and foods, which displace the breast milk that the child requires for adequate growth and development. Active counselling and health promotion is required at the time of delivery, both by encouraging early breast-feeding and by helping mothers with problems. 30 World Health Organisation. Complementary feeding of young children in developing countries: a review of current scientific knowledge. 1998. WHO/NUT/98.1.31 UNICEF, Multiple indicator cluster survey in FRYROM with micronutrient component, November 1999.32 Action Against Hunger – UK, Infant feeding and weaning survey, Kosovo. 15-27 July 1999.



In infants under 6 months of age additional drinks reduce the baby's hunger thereby reducing the quantity of milk suckled from the breast. In all children care must be taken with the water to ensure that it is boiled and cooled to reduce gastrointestinal infections. Russian tea is not a suitable drink for infants under 5 years as it can reduce iron absorption.Both cows milk and Russian tea could contribute to the incidence of diarrhoea in infants if they receive them before their intestines are fully developed. In addition very early introduction of cow’s milk has implications for renal damage due to the quantity of protein and the sodium load. Cows milk may also induce atopy, notably asthma and eczema, and in some cases the child may develop temporary lactose intolerance following diarrhoea.

Complementary foodsIn infants under 6 months of age additional drinks reduce the baby's hunger thereby reducing the quantity of milk suckled from the breast. In all children care must be taken with the water to ensure that it is boiled and cooled to reduce gastrointestinal infections. Russian tea is not a suitable drink for infants under 5 years as it can reduce iron absorption.A majority of infants in Kosovo are weaned onto biscuits and cows milk, which may or may not be mixed with extra sugar. A large number of infants are given a biscuit mix marketed directly at infants. The most popular brand is “Plazma”. The problem with using biscuits or traditional flour based porridge as a weaning food is that although they are filling and provide energy, biscuits are nutritionally poor and provide inadequate vitamins and minerals. In addition, this product is often started at 3-6 months and as a wheat-containing product this is too early for introduction. The infant’s intestine is not sufficiently developed until 6-8 months to deal with the protein type, and the child’s gut may have problems digesting the wheat, which can result in diarrhoea.

Infant formula The predominant source of nutrition for infants who did not receive breast milk was self-reported as family food and cows milk. 15.9% of mothers reported using infant formula, and of these only 35% of the infants received the correct volume of formula for their age. This is very worrying as an inadequate amount could mean that the child does not receive enough energy, protein and micronutrients from the formula, ultimately impacting on their growth. It must be noted that infant formula use in July 1999 was reported at 25%. This reduction could indicate a gradual reduction in availability following the initial surge of donations post conflict.

The UNICEF study carried out in Macedonia33 reported that a fifth of the infants were using infant formula. This is currently higher than in Kosovo, but it could be expected that the incidence will increase as the economy becomes stronger and the province more developed.

Absorption of micronutrients




Use of non-breast milk foods and fluids may interfere with the bioavailability of certain key nutrients in breast milk, such as iron and zinc. Even though the concentrations of these nutrients in human milk are relatively low, when the infant is exclusively breast fed the percentage absorbed is high34. Iron absorption from human milk has been proven to be substantially reduced by consumption of other foods35.

Socio-economic ContextIt is important not to forget that child feeding takes place in a broader context of multiple social, political, economic and cultural forces. Dietary intake and illness are influenced by the underlying factors of household food security; available health care services and child care practices. Childcare practices are determined to a degree by the ability of the carers to gain access to economic, human and organisational resources in order to provide adequate complementary foods and care. The following table lists some of the factors that effect complementary feeding practices at the household and community levels. All of these factors clearly play a role in the infant feeding practices in Kosovo. Factors affecting infant feeding practice Application to situation in KosovoHealth and nutritional status Moderate to high incidence of chronic

malnutrition, diarrhoea and anaemia in young children in comparison with other European countries, and when taking into account the epidemiological picture.

Caregiver education, knowledge and beliefs

Variable depending on the schooling received, traditional practices of the family, practices of the mother in law and rural/urban location.

Autonomy, control of resources and intra household allocation

Kosovo society is highly patriarchal and the women's autonomy and decision making capacity is variable. Allocation of foods within the family.

Workload and time constraints A large number of families are heavily involved in reconstruction of their houses.

Mental health, stress and self confidence A high level of post traumatic stress has been identified in both adults and children post conflict36

Social support from family members and community

A degree of community breakdown has been recorded37 post conflict when the families resources have been stretched to the limit

34 Sandstrom, B., Cederblad, A., Lonnerdal, B. (1983) Iron absorption from human milk, cows milk and infant formulas. American journal of diseases of children, 137:726-729.35 Oksi, F., A., Landaw, S., A. (1980) Inhibition of iron absorbtion from human milk by baby food. American journal of diseases of children, 134:1519-1524.36 IRC, IPH - Pristina, WHO, CDC. Kosovar Albanian Health Survey Report, September 1999. Prepared by Spiegal, P., & Salama, P., International Emergencies & Refugee Health branch, Centers for Disease Control & Prevention, Atlanta, USA.37 Action Against Hunger, Food Security Survey, Kosovo, January 2000.



7.0 Conclusion

Action Against Hunger – UK remains concerned about the observed breastfeeding and infant feeding practices in Kosovo. In this report the combination of questionnaire and key informant discussions have further illuminated the need for changes in practices, which do not follow international recommendations. These changes require a concerted and committed effort throughout the community from the mothers to policy makers.

The problems are threefold and result from too early a termination of exclusive breastfeeding, the premature introduction of extra fluids and food and the late introduction of a complete family diet. The incidence of currently breastfed infants at 55% with those exclusively fed at 20% indicates a large number not in receipt of this most natural and formulated food for infants. The survey indicated that 8% of infants had never been breastfed. The number of mothers ceasing to breastfeed before 6 months, although much lower than in the July survey still leaves room for improvement. However the majority of mothers stop breast-feeding when the infants are less than 3 months. The major reason given for stopping was insufficient milk for the infant. It appears a large number at some point breastfed (92%) their infants. The rapidity with which this level falls may be due to the perceived problems of insufficient milk or the introduction of other fluids/food. This indicates that mothers are either not seeking or receiving adequate support and correct advice regarding breastfeeding and milk production. Further insights into why Kosovo mothers think their milk is insufficient should be investigated. This will help in any education programme aimed at changing attitudes. In addition any education or awareness programme should also include information for mothers to understand their own bodies and the processes involved in breast milk production as well as proper attachment.

Even though the mothers in this survey thought that breast milk is the most important fluid for their infant they still added or would like to include extra fluids to the diet of their infants. Key informant discussion suggests that they are keen to add extra fluids such as water, juices, tea, infant formula and cows milk. The latter two are perceived to provide extra nutrients and it is clear that these are being introduced too early.

Although the economy is recovering, the cost of infant formulas is still prohibitive to a majority of families. This means that although they would like to use formula they are unable to or they purchase insufficient amounts to feed the infant sufficiently for 6 months. It is not clear if the lower usage is due solely to economic factors and availability especially in rural areas or the result of lower numbers of international donations. Efforts to sensitise the humanitarian communities to the dangers of breast milk substitutes continue. In this study a large percentage of vulnerable groups (11.9% IDPs and 22.1% social cases) were found. Their economic capabilities play a role on their infant feeding practices.

A surprising finding is that mothers are giving extra fluid in the form of water. Although not harmful, water is not necessary, as research has shown that even in tropical countries if an infant is breastfed on demand sufficient fluid is produced in breast milk to meet their



requirements. Water fills the stomachs of infants and reduces their intake for nutrients. The use of a bottle, which is the main method of delivery, introduces the risk of infection.

The results from the last and present survey showed worryingly that introduction of food to infants are far too early. This is confirmed by the information given by mothers outlining what they thought a child of different ages should be receiving. This causes a number of problems firstly the fluids and other foods displace breast milk. The production of breast milk is reduced if the infant does not suckle frequently. The timing of food introduction needs to be made clear so that infants <6months are exclusively breastfed as much as is possible. Thereafter correct and balanced introduction of complementary foods can be given.

Although mothers would like to give fruit and vegetables they are relatively expensive. This may pose a problem for the internally displaced and socially vulnerable families which are financially more limited. The worrying aspect of this is that a large number of infants may not be receiving sufficient micronutrients in their diets. Micronutrients such as vitamin A, iron and zinc are required for normal growth and development. Deficiencies contribute to impaired intelligence, energy reduction, lower productivity, infant and childhood mortality and morbidity. Kosovo society places a high value on, meat products. It is worth, linking any education so that they give messages on a diversified diet, which includes micronutrient rich foods.

There is very little advice and support for women at prenatal and postnatal levels regarding breastfeeding and appropriate infant feeding. Efforts by humanitarian organisations in this aspect are continuing but require cohesive and coordinated action. This requires transformation at the policy level in order to make these changes in practices as well as in attitudes. Changes also need to be directed at all levels for instance the commencement of a baby friendly hospital initiative will ensure that the mother and infant have a good start. Support and encouragement at the hospital level can then be pursued at the primary health care level when the mothers are at home. Education of health professionals and the community at large will ensure the consistentency of the messages.

Breastfeeding and nutrition education should become part of any health promoting activities as correct feeding and hence balanced diets contribute to good health. This in turn leads to the national well being in terms of reduced demands on the health service and increased work output.



8.0 Recommendations

In order to promote and protect breast-feeding and infant feeding practice in Kosovo the following recommendations should be acted upon.

1. Clear up to date education about good breast-feeding and infant feeding practices to the following groups; Mothers In hospitals to key staff dealing with infants in the hospital. In particular the

neonatal, gynaecology, maternity, and paediatric wards should be targeted. Ideally this should be carried out by the UNICEF Baby Friendly Hospital Initiative.

All health professionals involved with infants and pregnant/ lactating mothers. International expatriate staff dealing with infants and pregnant/lactating mothers,

both directly and indirectly. All international and national humanitarian organisations involved both directly and

indirectly in the distribution of food and specialist infant weaning products. All health professional at the faculty level.

2. All handling and utilisation of Breast Milk Substitutes should follow the UNMiK working document titled "Joint UN agency statement on donations of breast milk substitutes". See annexe 11.

3. Development of nationally accepted guidelines endorsed by WHO for vitamin and mineral supplementation, especially in relation to Iron, Zinc, Folic Acid and Vitamins A and D.

4. Breast feeding education should concentrate on the following messages; Exclusive breast feeding, to ensure other drinks and foods are not introduced

before 4-6 months of age Breast milk supplies protective immunoglobins, which protect against infections

such as, enter colitis, unlike infant formula Breast milk is free, the correct temperature and always available, whereas infant

formula is expensive and associated with a higher risk of infection for the child. Cows milk should preferably not be given to infants. What foods and drinks should be introduced and when

5. The indicated micronutrient problem should be further investigated using biochemical indicators to assess the extent of the problem. This should concentrate on:

Iron deficiency anaemia Rickets Vitamin A deficiency

6. Vulnerable groups/regions could be targeted for a nutrition support program, using for example food coupons or distribution of food products with normal or modified nutrient composition. This should be carried out under the surveillance of the health system.



9.0 Some Useful Publications and contacts

1. Mothers and Education.

Breast-feeding; How to support success, Copenhagen, WHO Regional Office for Europe, 1996.

Infant feeding in Emergencies: A guide for mothers, Copenhagen, WHO Regional Office for Europe, revised 1997.

2. Policy and Health Worker Education.

Ten successful steps to breast feeding, Infant feeding in Emergencies, Nutrition Unit, Copenhagen, Who Regional Office for Europe, revised 1997

Re-Lactation: Review of experience and recommendations for practice.WHO Department of Child and Adolescent Health Development, 1997.

Infant Feeding in emergencies: Policy, Strategy and Practice. Report of the ad Hoc Group on infant feeding in emergencies, May 1999.

Complementary Feeding of young children in developing countries - a review of current scientific knowledge, WHO, Geneva 1998.

Contacts:

Action Against Hunger-UKFrances Mason, Technical Co-ordinator, Nutrition and Food Security.1 Catton StreetLondon, WC1R 4ABUnited Kingdom++44 171 831 5858

Action Against Hunger-USAAnne-Sophie Fournier, Technical Co-ordinator, Nutrition and Food Security.875 Avenue of the AmericasSuite 1905New York, New York 10001USA++1212 967 7800

Action Contre la FaimClaudine Prudhon, Technical Co-ordinator, Nutrition and Food Security.4 rue Niepce75014 ParisFrance++331 4335 8888



Action Contra el HambrePhilippe Paul, Technical Co-ordinator, Medical and Nutrition.C/ Caracus 6 No. 128010 MadridSpain++3491 391 5300

WHO Regional Office for Europe,Dr Aileen Robertson, acting Regional Adviser,Nutrition Policy, Infant Feeding, and Food Security Programme,Lifestyles and Health Unit,8 Scherfigsvej, DK-2100 Copenhagen, Denmark.Tel ++45 39 17 13 62. Fax ++45 39 17 18 54.

WHO Headquarters,Ms Randa Saadeh, Technical Officer, Nutrition Unit,Dr Felicity Savage King, medical Officer,Division of Child Health and Development,Avenue Appia, CH-1211 Geneva 21, Switzerland.Tel ++41 42 791 21 11. Fax ++41 22 791 23 00.

UNICEF.Ms Hind Khatib,Palias des Nations, CH-1211, Geneva 10, Switzerland.Tel ++41 22 909 56 17, Fax ++41 22 909 59 09.



ANNEXES

* Refer to annexes from Anthropometric report under the same binding.

Annexe 1: Map of Kosovo by Municipality -see Anthropometric report Annexe 1*

Annexe 2: Cluster Allocation by Municipality - see Anthropometric report Annexe 3*

Annexe 3: Changes to Original Cluster Allocation - see Anthropometric report Annexe 4*

Annexe 4: Personnel List by Team

Annexe 5: Breast feeding / infant feeding questionnaire

Annexe 6: Key Informant sites

Annexe 7: Key informant discussion outline

Annexe 8: Approved selection criteria for the distribution of humanitarian food aid in Kosovo

Annexe 9: Joint UN agency statement on donations of breast milk substitutes



ANNEXE 4 Personnel List by Team (only the females are listed as the males did not carry out the questioning)

TEAM 1:

Lindete LikaSherife Ramadani

TEAM 2:

Magbule MaziqiMimoza Alishani

TEAM 3:

Vlora MaliqiBytyci Shqipe

TEAM 4:

Albina LikajMaim BerishaHyrmete Hoxha

TEAM 5:

Nora KecmendiMelihate Limani

TEAM 6:

Lumnije K. ShillovaHikmete Limani

Selvije Saqipi

DATA ENTRY:

Arta ZeqirajNehare Zeqiraj



ANNEXE 5 Breast Feeding / Infant Feeding Questionnaire

Infant Feeding Questionnaire

Date: _____/_____/_____Team no:___________________________Village/district:______________________House destroyed Not destroyed Urban Rural MTS selection criteria 1 2 3 4 4.1 4.2 4.3 4.4 4.5 None

All questions should be asked to mothers/carers of children 0-≤24 months.

Child number:_____________ Cluster no.:_______________Child date of birth_____/_____/_____ Sex: M F Age of mother_____________

Section 1 - Breast Feeding

Which of the following best describe the child? (only choose 1 option)Currently breast fed Previously breast fed Never breast fed (go to Section 2)

Which kind of breast feeding does the child receive? (only choose 1 option)Exclusive breast feeding (go to Question 4)Predominant breast feeding (go to Question 3)Mixed feeding “Don’t know/no answer “

NB. Exclusive BF is only breast milk and nothing else, predominant is mostly breast milk, but also some drinks or some food.

If the child was exclusively breast feed, how old were they when food or drink were introduced ?______weeks/months

How important do you think breast feeding is? Please rank in order of importance to the child’s well being? (mark on the line)

I______I______I______I______I______I______I______I______I1 2 3 4 5Not important Very important

Has the child received any of the following drinks or food in the last 24 hours? (Can choose more than 1 option) Infant formula Yes No Volume______cups Plain water Yes No Volume______cups Sweetened water, or juice Yes No Volume______cupsRussian or Indian tea Yes No Volume______cupsFlower tea Yes No Volume______cups



Cows milk Yes No Volume______cupsPowdered milk Yes No Volume______cupsOther………………………………………………………………………………………..(1 small bottle=125ml, 1 big bottle=250mls, 1 cup=250mls)

What is mainly used to give these fluids to the child? (Only choose 1 option)Bottle Yes No Cup Yes No Cup and spoon Yes No Other……………………………………………………………………………………….

Please rank the following in order of current importance;Example: Compare IF and BM if the mother feels that IF is more important than BM then put IF in the first box.

Infant Formula Breast Milk Cows milk Tea with sugarInfant Formula

XBreast Milk

X XCows milk

X X XTea with sugar

X X X X

What food would you normally give or exclude from the diet of an unwell child?

Food give:……………………………………………………………………………………………….Food exclude: ………………………..…………………………………………………………………

If the child has diarrhoea does the mother give more or less of the following? (Can choose more than 1 option)1) Breast milk More Less Same None 2) Russian/Indian tea More Less Same None 3) Flower tea More Less Same None 4) Plain water More Less Same None 5) Cows milk More Less Same None 6) Sweetened water, or juice More Less Same None 7) Other……………………… More Less Same None

From whom did you receive information advice on breast feeding or introduction of food from? Yes (If yes go to 11, can choose more than 1 option) No Mother Mother in law Husband Sisters Friends Father/brother Grandmother Doctor Nurse Other……………………………………………………………………



Who do you go to for help if you have a problem with breast feeding?……………………………………………………………………………………………………………………………………………………………………………………………………………………

If not breast feeding now when did the child stop? (Only choose 1 option)0-<3 months 3-<6 months 6-<9 months 4) 9-<12 months 5) 12-<18 months 18-24 months

What was the main reason that the mother/child stopped breast feeding? (Only choose 1 option)1) Insufficient milk 2)Baby was too old 3) Baby refused Mother was sick Baby was too thin or sick Baby needed more than breast milk Lack of time Mother was under stress Mother became pregnant Infant formula better than breast milk Doctor advised to stop Mother felt quality was poor Other…………………………………………………………….

Section 2 – Non- breast feeders

14. If the child is not breast fed, what are the main reasons for this?………………………………………………………………………………………………………………………………………………………………………………………………………………………..

15.If the child is not breast fed what is their main source of nutrition?…..…………………………………………………………………………………………………………..………………………………………………………………………………………………………

16.For those children who did not receive breast milk, what have they received in the last 24 hours? (Can choose more than 1 option)1) Infant formula Yes No Volume______cupsPlain water Yes No Volume______cups3) Sweetened water, tea or juice Yes No Volume______cupsRussian or Indian tea Yes No Volume______cupsFlower tea Yes No Volume______cupsCows milk Yes No Volume______cupsPowdered milk Yes No Volume______cupsOther………………………..………………………………………………………………

17.If they received infant formula, how many bottles of infant formula does the child receive per day? (Choose only 1 option)1 bottle 2 bottles 3 bottles 4 bottles 5 bottles 6 bottles



7 bottles ≥8 bottles Ask to see the bottle and calculate the mls per bottle, according to how much the child normally finishes ……………………..mls

18.Where does your water come which you use to make the infant formula with?Well (with pump) 2) Well (with bucket) 3) Spring 4) Public water supply Other………………………………………………………………………………..

19. How much money does the family spend per month on infant formula?1) . ……………………………………………………..Dinnar…………………………………………………….. DM

Or is it provided by an organization;3) MTS 4) NGO 5)Other……………………………………………………………………

Section 3 – Introduction of foods (ask to all mothers)

20. Is the child currently eating a “typical” diet for them?Yes (go to Q 22)No (go to Q 21)Don’t know

21.If not eating a “typical” diet, why not?1) Illness 2) Lack of access to normal foods 3) Lack of money3) Other…………………………………………………………………………………………...

22. Has the child received any of the following foodstuffs in the last 24 hours?

Foodstuff Yes No Don’t know Number of portions

Yoghurt

Cheese

Bread

Foodstuff Yes No Don’t know Number of portions Rice

Biscuits and cakes

Griz

Kacamak



Rice porridge

Flea

Meat

Fish

Eggs

Pasta

Beans

Apples, pears

Oranges, lemons

Bananas, Grapes

Spinach

Cabbage

Cauliflower

Carrots, Peppers, TomatoesOnions, leeks

Sweets

Fizzy drinks

Other (please expand on the dishes which are made up of mixed ingredients) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

23. Which foods and drinks should children receive at the following ages? (Please fill in each line)2-3 months………………………………………………………………………………………….4-5 months………………………………………………………………………………………….6-7 months………………………………………………………………………………………….8-9 months………………………………………………………………………………………….10-11 months…………………………………………………………………………………...…..12 months and onwards……………………………..……………………………….…………....……………………………………………………………………………………………………

24. Why do children become anaemic in your opinion? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………

26. What are the main constraints to feeding your child normally?



………………………………………………………………………………………………………………………………………………………………………………………………………………

Please thank the person for their time in completing this questionnaire.



ANNEXE 6 Key Informant Sites

Name of Municipality Village/town visited Key informant discussions

Albanian Serbian Albanian SerbianMitrovice Kosovska

MitrovicaMitrovice Kosovska

Mitrovica

Podujeve Podujevo Llapashtice e Poshteme

Donja Lapastica

Gllogovc Glogovac Gllanaselle Gladno Selo

TOTAL 3 3 3 3



ANNEXE 7 Key Informant Discussion Guideline

To be carried out with all groups of women who have had children: young mothers, middle aged mothers, older mothers and grandmothers.

What do they think about;

Importance of breast feeding

Exclusive breast feeding

Order of importance of Breast milk, Infant formula, Cows milk, Tea with sugar

Problems with breast feeding;

Who do they get support from if they have problems BF

What problems do they/have they had

If a child receives infant formula what are the main reasons

Introduction of family foods to the diet;

At what age did they/should you introduce family foods

Unwell children;

What foods do they/did they give or exclude from the diet of an sick child

Why do they think children become anaemic



Changes in their practices;

Have their infant feeding and breast feeding practices changed since the conflict

What are their main constraints to feeding their children as they would wish



ANNEXE 8 Approved Selection Criteria for the distribution of humanitarian food Aid in Kosovo

Category Definition1 Families without shelter whose houses have been badly or totally

destroyed (UNHCR categories 3-5)

2 Internally displaced families (IDP) (with host family or in collective center), due to inhibitive/emergency conditions in own home/original area of residence and without access to food, and;

2.2 Families hosting IDP's are eligible to receive a standard food ration

3 Families which are permanently unable to generate an income, have no access to other financial support nor to food, such as;Households with only elderly (60 years of age and above) personsHouseholds with only elderly persons and children under 16 years of ageHouseholds with only elderly persons and handicapped persons, etc.

4 Social cases according to the following sub categories priority;

4.1 Single parent household with no access to income and to food

4.2 Families with more than three children, no income and no access to food

4.3 Families with less than 50 dm income available per person per month and no access to food

4.4 Families with income generating potential but presently unemployed and with no access to food

4.5 Families with income between 50 and 80 DM per month and no access to food are entitled to half a ration



Annexe 9 UN Civil Administration

Secretariat for HealthPristine, 15 October 1999

Joint UN Agency Statement on Donations of Breast-Milk Substitutes

In the weeks since families have begun to return to Kosovo there have been increasing reports that breast-milk substitutes and bottles have been donated without reference to long-standing UN policies.The basis for these policies is the International Code of Marketing of Breast-Milk Substitutes, which regulates the circumstances under which breast-milk substitutes may be donated. Because of both the hygienic risk and the risk of confusing the infant’s suckling at the breast, the distribution of bottles with teats and dummies (pacifiers) is also regulated for babies receiving breast-milk substitutes temporarily, while measures are being taken to improve their mothers’ milk supplies or long-term, where breast feeding is not an option then cup feeding is recommended.These guidelines, meant to contribute to successful breast-feeding of all infants in every part of the world, are especially critical in emergency situations or where basic amenities such as clean water and fuel are not reliably available.Protecting breast-feeding is also an important public health strategy for achieving Policy Target 1 – “ A Healthy Start in Life” in the new Interim Health Policy Guidelines for Kosovo. Integrating the Code and related UN policies into the action plan for the next six month is crucial part of protecting breast-feeding and child health in Kosovo.

In practical terms adherence to the Code and related UN policies means:

No general distribution to families or families or institutions of breast- milk substitutes including infant formula, dried milk powder, juices, baby teas and other liquids intended for bottle feeding.No general distribution to families or bottles and teats (nipples) or dummies (pacifiers)No general distribution to families or institutions of complementary (weaning) foods intended for infants under the age of 4-6 months.Infant formula may, in certain circumstances, be donated for specific infants. Such donations must be distributed through the local health house or family practitioner or, in other absence, through the closest health NGO.When donations of infant formula are requested or prescriptions for it are written for specific infants health care facility or health NGO must first determine the mother’s lactation status. Counselling for the mother on improving or restoring her milk production should be part of any comprehensive feeding program for her baby.In emergency situations or where hygienic conditions cannot be assured, any baby receiving a breast-milk substitute should be fed cup.The Code requires that donations of a breast-milk substitute for specific infants guaranteed by the donor for as long as the infants need it.Donated breast-milk substitutes (including cow’s milk) and those for sale must be generically (no brand name) labelled and carry both a statement on the importance of breast-feeding and clear instructions for using the product in a language understood by the infant’s family.

Endorsed by the Joint Civil Commission



Annexe 10 Use of breast milk substitutes

Attention all procurement agencies

It has come to our attention that products (infant formula, cows milk products, infant cereals, pots of pureed baby food & baby bottles) aimed at feeding young infants continue to come into Kosovo.

We would like to bring to your attention the following points;

Nearly all women can breast feed their babies.

WHO / UNICEF strongly recommend that breast milk alone has everything the baby needs to grow well in the first 6 months of life.

Giving infant formula or similar products is counterproductive to breast feeding which is healthy and safe.

Even underweight and traumatized mothers produce adequate quantities of good quality milk.

Feeding the mother would be a more cost effective and safe way of ensuring good nutrition for both mother and child.

Any NECESSARY, infant feeding products should be MEDICALLY TARGETED and supplied in quantities sufficient to feed the recipient infants as long as they need the product. These products should be labelled clearly in the appropriate language.

Mothers facing difficulties breast feeding need medical counselling and a lot of encouragement, not a tin of infant formula.

Imagine yourself living as a mother in Kosovo. The water from the well is not always clean, and the firewood supply is poor. The house is crowded and hygiene is difficult to maintain. Your baby is screaming to be fed.

Q. How do you make up a bottle of powdered milk properly in this situation?

A. You can't - but if you are breastfeeding your baby, you don't need to!If you receive infant formula from outside donations, please contact Action Against Hunger, UNICEF or WHO immediately.


Documents

Introduction: · Web viewDairy products, dark green vegetables, orange / red fruits and vegetables Good intake of dairy products, variable intake of vegetables / fruit Moderate night