Human milk offers the nutrients that a child needs to begin a healthy
life and represents the essential food for infants until their sixth
month of life, as an exclusive food, and from then onwards should
be complemented with other sources of nutrition until at least 2
years of age ().
Earlier World Health Organization (WHO) documents recommended exclusive
breastfeeding for 4-6 months ().
Based on scientific evidence of the benefits of exclusive breastfeeding,
many countries, including Brazil, officially adopted the recommendation
of complementary foods at 6 months of age ().
Nowadays the WHO and domestic policy concur on the recommendation
of exclusive breastfeeding for the first 6 months of life ().
In search of a consensus on the optimum duration of exclusive breastfeeding,
the WHO performed a systematic review of published research and
concluded that none of them demonstrated weight or height gain deficits
for children exclusively fed breastmilk during the first six months
of their lives ().
The principal justification against the introduction of complementary
foodstuffs before the sixth month of life was the increased risk
of episodes of gastrointestinal infections ().
In addition to the increased infant morbidity and mortality, there
are innumerable disadvantages to the precipitate introduction of
complementary foods, of note among which are the interference in
nutrient absorption, such as iron and zinc (),
the increased risk of food allergies ()
and the increased incidence of chronic-degenerative diseases during
adult life ().
Furthermore, with the introduction of complementary foods before
6 months of age, the child will receive less human milk, with a
consequent reduction in milk production on the part of the nurturing
a reduced overall breastfeeding duration, a reduction in the efficacy
of lactation as a contraceptive ()
and interference in the baby's feeding habits ().
Even among non-breastfed children, the habitual recommendation for
the introduction of solid foods is after 4 months of life ().
Notwithstanding the nutrition of a population does not only depend
upon their access to adequate nutrition, but, more than anything
else, on the education and culture of that population. Nutritional
education begins extremely early, during the first months of life
when the foundations of feeding habits are constructed ().
The feeding behavior of a child is determined by its interaction
with food, by its anatomophysiological development and by emotional,
psychological, socioeconomic and cultural factors ().
Even so, the most marked influence on the formation of feeding habits
is brought to bear by the product of the child's interaction with
its mother or the person most involved with its feeding ().
It is important to remember that infants ingest the foods that they
are offered and in the form that they are prepared.
The family offers a wide field for the child's social learning.
The domestic environment, the parents' lifestyle and interfamily
relationships can have a great influence on feeding and food preferences,
and affect the energetic equilibrium of nutrition, through the availability
and composition of foods. Thus, the family may establish the learning
of a socially acceptable habit or insert new habits, contributing
to the formation of an adequate or inadequate behavioral pattern
The objective of the present study was to describe the feeding
habits of breastfed and non-breastfed children, following the introduction
of liquid and semi-solid/solid foods during the first year of life.
The use of pacifiers was also investigated, with respect of the
presence or absence of breastfeeding. By means of an understanding
of the factors associated with feeding habits, educational and preventative
measures can be proposed for the formation of healthy feeding behavior
and for the promotion of the health of both children and adults.
This is a cross-sectional population-based study, approved by the
Ethics and Research Committee at the Universidade Federal da
Bahia. The study population was made up of children less than
one complete year old on the 25th of August, 2001, the Brazilian
national vaccination day. The children resided in the city of Feira
de Santana, presented at the selected vaccination stations and were
accompanied by their mothers, who responded to the questionnaire.
The design was for a simple random sample. Vaccination took place
at 62 units (health centers and schools). In order to ensure vaccination
coverage, the Feira de Santana Department of Health divided the
city into four "commands". A simple random sample was
selected from each stratum (command). Forty-four centers (71%) were
selected by drawing lots out of the total of 62. A sample was calculated
to represent 20% (1,912) of the estimated population of children
aged up to 11 months and 29 days (9,563). The questionnaire was
administered to 2,323 (24.3%) mothers.
Data collection was performed by 104 previously trained university
students. The data collection form was developed in clear and objective
language with closed, mutually exclusive, possible responses, in
the majority of cases: yes, no and don't know. The questionnaire
was administered in the form of direct interview. In order to assess
the foodstuffs that were given to the children, a 24-hour dietary
recall was used.
The two main variables under study were breastfeeding (primary
independent variable) and feeding habit (dependent variable). Feeding
habits were analyzed according to the type of complementary foods
introduced into the child's diet, and their age on introduction.
External variables investigated as having a possible influence on
the primary association were: age of the child in days, sex, birth
weight and pacifier sucking habit. Maternal characteristics investigated
were: age, birth order, education, employment outside of the home
and family income.
Complementary foods are defined as any liquid, semi-liquid or solid
food offered to the breastfed child ().
The liquid foods investigated were water, teas and juices and semi-solid
foods were mashed fruit and vegetables. The family meal was defined
as a solid food prepared for normal adult consumption. Mothers who
claimed to give nothing but breastmilk to their children were defined
as in exclusive breastfeeding.
For the data analysis association measurements (prevalence ratio),
with 95% confidence intervals and statistical significance were
calculated using the chi-square test with its respective p value.
The statistical program employed was the Statistical Package for
Social Science (SPSS), version 10.0.
Two thousand, three hundred and twenty-three mothers were interviewed,
with four questionnaires being discarded due to incomplete data.
On the data collection day, 69.2% (1,603) of those less than one
year old were breastfeeding. The prevalence of exclusive breastfeeding
among those with ages less than or equal to 4 and 6 months, was
48.3 and 38.5%, respectively.
Maternal characteristics were as follows: 58.8% were in the 20-29
age group, 46.2% were primiparous and 23.3% were employed outside
of the family home. Of the 1,640 mothers who were able to provide
their family income, 49.6% said that it was between one and two
times the Brazilian minimum wage. In terms of education, 37.5% had
continued beyond compulsory basic education. Fifty-two point eight
percent of the 2,319 children studies were aged 6 months or less,
7.3% were born weighing less than 2,500 grams, and 49.9% were male.
During their first month of life, breastfed children were already
drinking water (7.3%), teas (23.2%) and juices (2.7%) (Figure 1),
although the non-breastfed children's consumption was significantly
greater, when compared with the breastfed subset, being, for water,
teas and juices, respectively, 30% (p = 0.01), 50% (p = 0.05) and
30% (p = 0.000).
Figure 1 -
Prevalence of children aged 6 months or less
who drank water, juice and tea during the 24 hours before the survey
Consumption of semi-solid/solid foods by breastfed children during
the first month of life was at 0.7% for mashed fruit and the family
meal, and 2% for mashed vegetables. No significant increase was
observed in the consumption of these foods during the first 3 months
of life (Figure 2). The non-breastfed infants consumed significantly
more fruit and vegetable mashes and family meals during the first
month of life, respectively, 10% (p = 0.01), 20% (p = 0.02) and
10% (p = 0.01).
Figure 2 -
Prevalence of children aged 6 months or less who ate mashed fruit
and vegetables and family meal during the 24 hours before the survey
Non-breastfed children aged four months or less presented significantly
higher prevalence of water, tea, juice and fruit mash consumption
than did breastfed children (Table 1). For the same age range, non-breastfed
infants presented significantly greater chances of consuming mashed
vegetables and family meals prematurely (Table 1). When pacifier
use was compared between these two groups, significant differences
were also observed, with greater prevalence among the non-breastfed
children (Table 1).
Table 1 -
Consumption of water, juice, tea, mashed fruit and vegetables,
family meals and use of pacifier according to the presence or absence
of breastfeeding in children aged 4 months of less
No statistically significant differences were observed when the
introduction of the family meal into the diets of children aged
four months or less was analyzed in terms of the maternal co-variables
recorded: aged less than 20 (p = 0.61), incomplete basic elementary
schooling (p = 0.19), employment away from home (p = 0.20), family
income less than twice the national minimum wage (p = 0.29).
In recent years scientific evidence has been accumulating giving
foundation to the importance of exclusive breastfeeding during the
first 6 months, and of sustaining breastfeeding until at least 2
years of age ().
While breastfeeding prevalence has been shown to be higher in the
city of Feira de Santana than the rates published in a number of
different national studies (),
and while breastfed children have better feeding habits when compared
with non-breastfed children, elevated consumption of liquids, particularly
teas, was also observed, right from the first month of life.
The steady consumption of teas, at all ages during the first year,
and the elevated consumption when compared with water and juices
during the first month, reinforce the conviction that, when mothers
are offering tea to their children the primary objective is not
infant nutrition, but medication, in keeping with cultural factors
that encourage the use of teas as treatments.
This, critical, situation has also been revealed in other studies
which also found premature introduction of teas and water into babies'
explained by the mothers as for colic, gasses and thirst ().
The rural influence that can be observed in the city of Feira de
Santana may help to explain the results, because it is known that
rural communities have more traditional habits and that in them
a large number of mothers begin breastfeeding and sustain it for
longer, although they introduce complementary foods too early ().
Clearly the non-breastfed children ingest artificial milk, especially
during the first months of life. One of the problems caused by the
ingestion of protein to young babies is related to the greater permeability
of the intestinal mucosa during the neonatal period and during the
first 3 months of life, whish results in the absorption of intact,
undigested proteins and immunoresponse to the protein antigens present
in milk-based formulae ().
This characteristic, in conjunction with immune mechanisms, explains
the large number of children who develop cow's milk intolerance,
not just because of the high antigenic power of the heterologous
protein, but also because of how early it is given ().
Cow's milk is responsible for 20% of food allergies ().
For this reason, many countries' recommendations on the feeding
of small children include delaying the introduction until 9-12 months
of certain foods, including cow's milk as being highly antigenic,
particularly when there is a family history of food allergy ().
It has been demonstrated that the use of foods other than breastmilk
in children's diets increases the risks of infant morbidity and
mortality due to conditions associated with early weaning ().
A case-control study assessing the impact of breastfeeding on hospital
admissions for pneumonia treatment, demonstrated that the rate of
hospitalization for this condition was significantly higher among
children who had received complementary feeding before 6 months,
both for breastfed children and those fed artificially ().
In a cohort study Arifeen demonstrated that exclusive breastfeeding
confers strong protection against death from diarrhea, and that
predominant breastfeeding or the absence of breastfeeding were associated
with a 2.2 times greater risk of dying from other infectious disease
causes, and a 3.9 times greater risk of dying from respiratory infections
and diarrhea ().
The current research showed that, during the first 3 months of
life, the consumption of semi-solid/solid foods by breastfed children
had low prevalence, increasing after the fourth month. It is possible
that the end of maternity leave and the mother's return to work
may contribute to the start of complementary feeding. It is also
worth pointing out that the recommendation of exclusive breastfeeding
for 4-6 months, still present in the majority of textbooks, based
on the WHO's previous recommendations (),
may have led health professionals themselves to tell mothers to
introduce complementary foods at this point, even in cases not defined
as hypogalactous, or for children growing well.
Still on the subject of semi-solid/solid foods, it was found that
children who are not breastfed consume them, inappropriately, right
from the neonatal period, with statistically significant differences,
when compared with those that are breastfed. Although the children
studied were already consuming some complementary foods, exhibited
better feeding habits than were found by the National Demographic
and Health Census (Pesquisa Nacional sobre Demografia e Saúde),
in which 52.9% of non-breastfed children and 6.2% of breastfed ones,
were already eating oats or cereals ().
In addition to the fact that children are not physiologically prepared
to digest solid foods before the sixth month of life, there is also
a neurological immaturity swallow non-liquid foods, shown by the
tongue protruding reflex with which they push away objects brought
against their lips and, normally, reject foods offered by spoon
Furthermore, chewing movements effectively begin at around 6 months,
the point at which the introduction of more viscous foods is recommended
Gastrointestinal disorders, in particular diarrhea, are common
among infants who are given foods containing starch prematurely
The introduction of other foods, such as cereals and vegetables
to the diet of breastfed children can prejudice the absorption of
iron through a chelation mechanism (),
and excess undigested starch can interfere with the absorption of
other foods and result in failure to thrive ().
Prepared food also involve greater risk of contamination resulting
in infectious diarrhea.
Malnutrition can be related to inadequate weaning practices and
the quality of foods consumed can be reflected, over both short
and long term, in child health, by a nutritional programming that
explains adult diseases related to inadequate nutritional practices
during the neonatal period ()
and childhood ().
Taking obesity as an example, breastfed children have a greater
capacity for controlling serum cholesterol levels than do those
receiving milk-based formula with implications for obesity prevention
in adulthood ().
In the studied population an association was found between the
use of pacifiers and early weaning. A number of different studies
have shown an inverse association between pacifier use and breastfeeding
One possible cause is the reduced frequency of daily suckling, which
may lead to reduced breast stimulation and diminished milk production
Nevertheless, a causal relationship has not yet been well-established.
One recent study suggested that pacifier use should be seen as an
indication of breastfeeding problems because mothers use pacifiers
when some difficulty with breastfeeding is encountered ().
Maternal education and family income are always included as determinants
in epidemiological studies. In this study however, no statistically
significant differences were found when the introduction of the
family meal to the diets of children four months old or less was
evaluated according to these variables. This fact suggests that
nutritional knowledge in Feira de Santana is related to references
that pervade all social strata, showing the need for the development
of studies that could widen our understanding of the cultural values
of the municipality.
Finally, the analysis of liquid and semi-liquid elements as consumed
by breastfed and non-breastfed children revealed that breastfeeding
was associated with better feeding habits, proven by the lower prevalence
of semi-solid/solid food consumption before the 4th month of life.
It was also found that the consumption of juice and water by breastfed
children interferes less than that of teas with exclusive breastfeeding
indicators, showing the need for intervention measures through educational
work with the population. It is known that to change culturally-established
is difficult and that continuous work is necessary which respects
the community's characteristics. For the process of change it is
important to make health professionals and opinion-formers more
aware and to stimulate educational programs to guide expectant mothers
and mothers about their children's nutrition during the first year
It is important to remember that the success of infant feeding
practices depend upon supplying children with food of adequate quality
that satisfies nutritional requirements, protects them from absorbing
foreign substances and does not exceed the functional capacity of
the gastrointestinal tract, in addition to being free of infectious
agents, all of which qualities are to be found in human milk.