Before current WHO recommendations came in to effect in 2005, the recommendation in Sri Lanka was to continue exclusive breastfeeding up to 4-6 months. In this study population, 67% of children had received exclusive breastfeeding up to 6 months. Children included in this study were between 24 and 60 months by the date of data collection in 2010. Some children included in the study were born in the same year in which the recommendation on duration of exclusive breastfeeding was changed. When a new recommendation is implemented it takes some time for it to get established. This study clearly demonstrates how exclusive breastfeeding rates up to 6 months have improved with time since implementation of the new recommendation in 2005. The exclusive breastfeeding rate up to 6 months in children who were 24 to 35 months of age at the time of the study was 79%, which is very high compared to other countries in the region.
Ministry of Health of Sri Lanka has enforced a strict breastfeeding code which strongly supports exclusive breastfeeding . Ministry of Health has also issued infant and young child feeding guidelines, which give specific instructions regarding exclusive breastfeeding and feeding after six months . In addition, most of the 10 steps in baby friendly hospital initiative, which are aimed at initiating and promoting exclusive breastfeeding at the time of birth, are adopted by hospitals in Sri Lanka. These factors, plus hard work done by primary health care workers in Sri Lanka, would have contributed to the high exclusive breastfeeding rates observed. An interventional study has been conducted in Gampaha district in 2006 on breastfeeding, which also trained public health midwives in lactation management . This also would have contributed to the above results.
The present economic state in the country demands females to be employed to meet the ever increasing cost of living. Female labour force participation in Sri Lanka was 32.8% in 2009 . In districts like Badulla, Nuwaraelliya, and Anuradhapura this was above 40%. Females employed in the government sector are entitled to full pay maternity leave for only 84 working days, excluding weekends and public holidays. This is equivalent to about 4 calendar months in Sri Lanka. Thus a mother planning to breastfeed exclusively for 6 months will have to take half pay leave as well. Further, lactating mothers working in the private sector do not enjoy same privileges as government employees. Therefore, if we are looking forward to improve exclusive breastfeeding rates further, it is important that fully paid maternity leave is extended up to 6 months, and that private sector employers also comply with regulations regarding maternity leave.
Of a total of 410 children, 17% of babies were on formula feeds and 34% were on complementary foods before 6 months of age. There is evidence that the early introduction of solids or formula can increase the risk of allergies and atopic conditions in later life. A review published in 2008 found that the risk of allergies in later life is high if solids were introduced before 3 to 4 months of age . However, the issue of adding solid foods after 4 months is more complex, where some studies have even shown reduced incidence of allergies when solids are introduced after 4 months rather than at 6 months . In this study, 23% of children had received complementary foods by 4 months, and almost all of these mothers had started solids without medical advice. A significant number of children (4%) had the introduction of complementary foods delayed up to 7 months, and in 2% of them it was delayed as much as 8 months. Delayed introduction of complementary feeding is a well known cause of growth failure and iron deficiency, as breast milk alone cannot provide adequate nutrients required by a child after 6 months. These issues regarding complementary feeding need urgent attention and correction.
A surprisingly high percentage (86%) of children have had infant formula, and more than half of these were on infant formula during the first year of life. Some mothers believe it is essential to give infant formula to children. It is not uncommon to find babies of non-working mothers who have adequate breast milk, are also on infant formula. When inquiries are made into the dietary history of these children, it is often revealed that there is no real indication for infant formula. When mothers are employed and away from home for a long period there may be a need to start infant formula for their children. However, when mother is away from home only for a short period of the day, expressed breast milk and complementary foods may be sufficient to support child's nutrition until the mother returns home to breastfeed. There should be clear instructions to mothers regarding when to consider starting infant formula for their children and to seek medical advice before commencing it.
Adding sugar to infant foods is not recommended until one year of age. This is because it will suppress the appetite and reduce the intake of proteins, increase the risk of dental caries, cause obesity and concerns about diabetes mellitus in later life. In this study, about 4% of children had sugar added to infant formula before 6 months, and about 44% had sugar added before one year.
Overnight feeding with infant formula is an identified risk factor for dental caries . Adding sugar to infant formula increases this risk substantially. However, there is no clear evidence in medical literature regarding the association between overnight breastfeeding and dental caries. Continuing overnight feeding for a long duration seems to be a common practice, as 83% of children were receiving overnight feeding even beyond 2 years of age. Though it is mainly with breast milk, 138 children (34%) were receiving overnight feeding with infant formula. Therefore, it is important to educate mothers not to continue overnight feeding in older children and not to add sugar to formula, even if it has to be given due to a specific indication.
Substantial numbers of children (72%) are breastfed beyond 2 years, and 42% of them are breastfed frequently throughout the day. Continuing too frequent breastfeeding, especially on demand, and offering breastfeeding when a child refuses a main meal will result in the child developing lack of interest in solids. This will result in growth faltering, as breast milk alone cannot support the growth of a child beyond 6 months. We very often come across children brought in by their parents complaining that child has poor appetite for solids, only to find that it is due to too frequent breastfeeding. There are specific instructions regarding breastfeeding beyond 2 years given in "Infant and young child feeding guidelines for Sri Lanka" issued by the Ministry of Health. It states that "Breastfeeding should be continued during the second year up to two years or beyond, given after main meals, not to breastfeed before main meals and not to replace a main meal with breast milk". However, these instructions either have not reached mothers or they have ignored them. We feel that correcting breastfeeding practices after 2 years is as important as enforcing exclusive breastfeeding during the first 6 months.
The main limitation of this study is the possible recall bias involved in collecting information regarding feeding practices in retrospect. The bias is likely to be high when a mother has more children. An educated mother is more likely to remember these details accurately, as she will be aware of the importance of this information, and may even keep records of them. In Sri Lanka, total fertility rate was 2.3 in 2006, and the female literacy rate in Gampaha district was 96.6 . Under such circumstances, we can assume that mothers will have a better chance of remembering details about their children. Further, during data collection we helped mothers to remember information by correlating feeding practices to other events like immunization. It was remarkable that almost all mothers recruited for the study had no difficulty in remembering exact details of their babies. However, we acknowledge that the recall bias would not have been totally eliminated.
This study was carried out in an area with close proximity to the capital and in an area with better socioeconomic condition than most parts of the country. Thus, we can assume that the situation in rest of the country is either similar or worse than this. Therefore, an interventional programme aimed at correcting issues highlighted by this study is indicated urgently.