AN EXTRACT OF THE REPORT ON INFANT-FEEDING PRACTICES WITH SPECIAL REFERENCE TO THE USE OF COMMERCIAL INFANT FOODS

Item

Title
AN EXTRACT OF THE REPORT
ON
INFANT-FEEDING PRACTICES
WITH SPECIAL REFERENCE TO
THE
USE OF COMMERCIAL
INFANT FOODS
extracted text
SDA-RF-CH-1.13 CH I.'3

AN EXTRACT OF THE REPORT
ON
INFANT-FEEDING PRACTICES
WITH SPECIAL REFERENCE TO
THE
USE OF COMMERCIAL
INFANT FOODS

By
P.V. Gopujkar, S.N. Chaudhuri, M.A. Ramaswami
M.S. Gore and C. Gopalan

NUTRITION FOUNDATION OF INDIA
Project funded by
UNICEF
1984

This booklet is provided to you as a public service by the United Nations Children’s
Fund (Regional Office for South Central Asia), New Delhi.

Introduction
The importance of the subject of infant-feeding hardly needs
emphasis. It is a subject which concerns not just the 25 to 30 million
babies that will be born annually in our country in the next decade,
and the several millions of mothers who will be rearing them. In the
ultimate analysis, it is very much a subject which deeply concerns the
very “quality” of the most precious of all our national assets—our
Fluman Resources The health and nutritional status of millions of
infants, and the ‘start’ which will influence their subsequent growth
and development through childhood will be determined by the patt­
ern of feeding during their infancy.

The subject has acquired added urgency and relevance in recent
times. The average infant mortality rate (1MR) in the country as a
whole, today stands at over 120 per thousand live births and has
remained more or less stationary around this figure for nearly a
decade. We have obviously a long way to go before we can achieve an
average I MR of less than 50—the target envisaged in the goal
“Health for All by' 2000 A.D.", to which we have officially
subscribed.
Our family planning programmes, apart from marginal success,
have generally failed to make the significant and substantial dent on
our population growth, which we are desperately looking for. Our
current inability to provide reasonable assurance of survival of child­
ren, especially among our poor communities, has not only denied our
family planning programmes the benefit of a valuable incentive; but,
indeed, it has also served to undermine the very moral and ethical
basis of these programmes as faras poor communities are concerned.
The prevention of undernutrition and diarrhoeal episodes, the
major factors underlying the current high 1MR, would greatly
depend on the successful promotion of wholesome and hygienic
infant-feeding practices.

There are new pressures on traditional infant-feeding practices
which should also occasion concern. The process of “development"

inevitably unleashes forces which may affect infant-feeding practi­
ces. Urbanisation, industrialisation, the bridging of the
'communication-gap' between the city and the village, increasing
employment opportunities for women, and such other factors incid­
ental to “development", are bound to exert their impact on life styles,
work-pattern, family structures and value systems in our communi­
ties, not onlv in the urban'areas but in the vast rural country-side as
well; and these, in turn, cannot fail to influence infant-feeding practi­
ces. Frequent monitoring of changing trends in infant-feeding practi­
ces is, therefore, necessary in societies in a highly dynamic state of
‘development’.

Till almost 60 years ago, in all countries of the world infants were
invariably breast-fed; ‘substitutes’ for breast milk were unknown.
During the last five decades, however, the practice of bottle-feeding
of infants with milk formulas (baby foods) had rapidly spread in the
technologically developed countries. It should not be surprising if
this trend increasingly becomes part of the “development process”of
poor developing countries as well Recent researches have revealed
the ‘unique properties of breast milk as the ideal and inimitable food
for the infant; as a result, it is now clear that all the modern techno­
logical ingenuity has not succeeded in producing a true substitute for
breast milk. With this recognition, active movements for promotion
of breast-feeding have started in the developed countries, already
with significant success. In this process, the fear has been voiced that
developing countries could become the happy hunting ground for
enterprising multi-national “baby food” manufacturers, who are
now being progressively denied an expanding market for their pro­
ducts in the developed countries.
Extensive studies carried out in India, nearly two decades ago,
notably at the National Institute of Nutrition, Hyderabad, had
shown that breast milk w’as the sheet-anchor of infant nutrition,
especially among our poor communities. The remarkable ‘feat’ of
Indian women of poor communities, weighing less than 40 kgs,
subsisting of diets providing less than 2000 K cal and 40 g protein,
putting forth 400-600 ml. of breast milk of good protein concentra­
tion, for several months on end, has been well documented in the
studies carried out at the National Institute of Nutrition. In the
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context of poverty and insanitary environment, the problem of
undernutrition in infants and children in these poor communities
would have been far worse but for this most valuable ‘gift’ of their
mothers. On the basis of these earlier studies, it may be computed
that the substitution of breast milk for infant-feeding by equivalent
quantities of even animal milk would cost the poor families a min­
imum of Rs. 100/-per mensem per infant, at the prevailing prices;
substitution by commercial infant foods would cost even more.'More
important than the economic implications of such substitution
would be the ‘health implications’—the greatly increased risks to the
infant of infections arising from unclean bottles and unsafe water.
The progressive substitution of breast milk by commercial infant
foods in the technologically developed countries during the last five
decades, had not produced any dramatic catastrophic results,
because of the vast superiority of their economic status and environ­
mental sanitation. In developing countries like India, however, such
substitution at the present state of economy, environmental hygiene
and health services, could prove truly catastrophic. At the present
time, when even developed countries, not beset with serious eco­
nomic and environmental sanitation problems, are actively promot­
ing movements for return to traditional breast-feeding, it will be
unfortunate if countries like India fail to take adequate steps to check
trends in the opposite direction.

National and international agencies have voiced concern over the
possible erosion of the salutary traditional practice of breast-feeding.
An International Code for the regulation of the marketing and
sales-promotion of commercial infant foods has been drawn up. A
similar Code, with some modifications has been adopted in India
also.
Unfortunately, however, w'hile a great deal of concern and excite­
ment has been generated over the question of “breast versus the
bottle", authentic recent data which will enable us to see the whole
problem in full perspective and provide the basis for action in this
area, are scanty. The important questions that need to be addressed
are: “Has there been any serious decline in traditional breast-feeding
practices in different communities in the different regions of India? If
so, how serious are these erosions? In particular, who are the people
3

using commercial infant foods, why are they using, how, and with
what result?

A comprehensive inter-country study on “Contemporary Patt­
erns of Breast-feeding” organised by WHO had addressed some of
these and other questions. Studies in India, carried out as part of this
project, which generated a lot of valuable information, were again
largely confined to the region in and around Hyderabad in Andhra
Pradesh.

It must also be remembered that there are more facets to the
problem of infant-feeding than the question of the use of commercial
infant foods. In fact, it is the threat of possible expanding use of
commercial infant foods, that has served to focus attention on these
other equally important aspects of infant-feeding, such as, the ade­
quacy of breast milk, the duration of breast-feeding, problems of
breast-feeding of infants of working women, appropriate supple­
mentation of breast milk, the state of nutrition of nursing mothers,
etc. Breast-feeding was, for long, almost taken for granted. To the
extent that the commercial infant food controversy has jolted health
scientists and policy-makers out of this complacent attitude, it may
have indeed rendered a distinct service to the cause of infant feeding.
The present Study, undertaken by the Nutrition Foundation of
India, was not confined to an examination of the use of commercial
infant foods alone. Obviously, this question had to be examined in
the total context of infant-feeding practices in general. This Study
was addressed to investigations of the patterns of infant-feeding
practices in three different regions of the country and among differ­
ent communities within each region. It is not claimed that the data
obtained are necessarily representative of the entire country but the
Study has at least covered some major centres where the impact of
‘development’ may be expected to be maximal.

Objectives of the Study
The objectives of the present Study were:
1) To survey the current infant-feeding practices in the commun­
ity with special reference to the use of commercial infant foods,
especailly those that are promoted as substitutes for breast milk in
4

different segments of the population and in different parts of the
country.

2) To obtain qualitative data on the type of food, including milk
other than breast milk, used for feeding infants under 12 months of
age, and the reasons why such foods are used or arc not used.
3) To study the manner and mode of use of different foods
including breast milk.
4) To obtain information on some health indicators of the infants
associated with these practices.

An Overview
In this Chapter, we briefly recapitulate some of the major find­
ings in the Study and discuss practical steps for the promotion of
wholesome infant-feeding practices in the country.
The major findings: (1) Our study shows that breast milk con­
tinues to occupy a place of pre-eminence in infant-feeding. Lactation
failures are so rare as to be practically insignificant. Thus out of 1820
infants in Bombay, there were ju/t 42 infants who were never breast­
fed (2.3%), out of 1377 in Calcutta only 26 (1.9%) and out of 1729
infants in Madras only 54 (3.1%) were never breast-fed. The majority
of these ‘never-breast-fed’ infants belonged to the highest incomegroup. Even these figures of ‘never-breast-fed’ infants may be an
over-estimate of true lactation failure because 11 of the 42 ‘neverbreast-fed’ infants in Bombay, 12 out of 26 in Calcutta and 15 out of
46 in Madras were not put to breast at all in the first instance. We
may, therefore, conclude that breast-feeding is the near-universal
practice, especially among the poor income-groups.

(2) Breast-feeding was maintained for long periods. Thu$ at the
age of 12 months, more than 85% of infants at Bombay, more than
90% at Calcutta and more than 70% at Madras were still receiving
breast milk.

However, these findings should not give room to the complacent
conclusion that traditional breast-feeding practices remain undis­
turbed. There are disturbing danger signals which, if not heeded in
5

time, could seriously worsen the current situation with respect to the
health and nutrition of our infants
(3) The practice of not putting the infant to breast within the first
24 hours and of discard i ng colostrum was widely prevalent especially
at Bombay and Madras, and to a much less extent at Calcutta.
(4) The disturbing finding was that a high proportion of mothers
did not (or could not) exclusively breast-feed their infants foreven up
to four months. Thus the percentage of exclusively breast-fed infants
at the end of the fourth month had declined to 66% at Bombay, 35%
at Calcutta and 45% at Madras.
(5) On the other hand, the undesirable practice of feeding infants
only breast milk without any supplements beyond six months was
also followed in a proportion of cases. Thus at the end of eight
months, 21% of infants at Bombay, 14% at Calcutta and 9% at
Madras were still exclusively on breast milk.

(6) 14% of all infants at Bombay, 36% at Calcutta and 42% at
Madras had received supplements of commercial milk foods (CM).
The use of CM was thus strikingly greater at Calcutta and Madras
than at Bombay. CM had been started within the first month in 3% of
infants at Bombay, 7% at Calcutta and 2% at Madras. These early
CM users included the ‘never-breast-fed’ infants referred to above.
(7) There was evidence that more children born in hospitals—
private or government—received CM and that health personnel had
‘advised’ CM to even poor families. Many health personnel, how­
ever, had also advised continued breast-feeding. CM users included
many rural poor who could not have had access to health personnel.
(8) Commercial cereal foods (CC) were used as supplements to
breast milk in 22% of infants at Bombay, 14%at Calcutta and 37%at
Madras.

(9) As may be expected, the proportion- of CM/CC users was
much higher among the higher income-groups but since the poor
constitute the vast majority of the population, when the actual
numbers of CM users in the general population were considered, the
great majority of users of commercial infant foods were the poor.
Most of these latter had resorted to CM on the basis of such beliefs
6

and considerations as “unique nutritious properties of CM”, “con­
venience”, etc. Obviously CM/CC enjoyed a prestige value in the
eyes of the poor. After all they were the foods which rich women were
using for their infants.
(10) CM/CC use was seen in a higher proportion of the metropol­
itan population, but the rural environs had not escaped their impact.
22% to 30% of all infants in the villages around the metropolitan
cities were receiving CM/CC, showing that the use of these foods was
by no means an urban elitist phenomenon. A good proportion of the
poor families was spending more than 10% of their meagre income
on commercial infant foods. Most of the poor were over-diluting CM
and feeding it in unhygienic ways and this was reflected in a higher
prevalence of severe grades of undernutrition in such children than in
those exclusively on breast milk.
(11) It was gratifying that the overwhelming majority of CM/CC
users were using these foods as supplements to breast milk and not as
substitutes. Indeed, among the poorest section these foods were
invariably given as supplements to breast milk and not as the sole
food.
(12) Our studies thus indicate that while CM/CC might not (as
yet) have totally supplanted breast milk among poor communities,
they have established for themselves a substantial ‘beach head’ in the
dietary patterns of even the poorest infants in the rural environs of
the metropolitan cities. At present they are only‘sharing’a place with
breast milk in the dietary of early infancy. With increased income­
generation they could make further inroads and progressively erode
the breast-feeding practice.
(13) Animal milk was the supplement of choice in all incomegroups at Bombay but CM/CC were the preferred supplements at
Calcutta and Madras among the higher income-groups. Even among
the poorest, CM/CC were more widely used at Calcutta and Madras
than at Bombay. Taking all Centres together, animal milk, at pres­
ent, has apparently a slight edge over commercial milk foods among
supplements of choice. However, commercial milk foods are running
practically neck to neck with animal milk in this regard; if present
trends continue, they may, before long, overtake animal milk and
7

become the major supplement of choice. On the other hand, if special
efforts are made to increase the availability of fresh animal milk and
to discourage the use of commercial milk foods, fresh animal milk
may further outstrip commercial milk foods to retain and improve its
present first place among supplements to breast milk.

(14) A smaller proportion of exclusively breast-fed infants had
suffered episodes of infection as compared to infants on supple­
ments, especially CM. The difference in the incidence of gastro­
intestinal disorders between exclusively breast-fed infants and those
receiving CM ICC was sign'ficant. Thus it was clear that unhygienic
use of CM ICC was taking its inevitable toll among the poor infants. ft
(15) Among infants less than six months of age, nearly a third at
Bombay, just more than a third at Madras and nearly half at Calcutta
had weights/age less than the lowest limit of normalcy on the Har­
vard scale. From l%to 15% of infants below’six months (l%-5% at
Bombay to 6% to 15% at Calcutta, with Madras in between) exhi­
bited what is generally referred to as Grade III undernutrition on the
Gomez’s scale. Exclusively breast-fed young infants show'ed better
growth than infants receiving supplements of CM/CC over and
above breast milk at Bombay and Madras. At Calcutta the growth
status of infants was poor, both in exclusively breast-fed infants and
in those receiving CC/CM supplements with breast milk, with the
latter showing marginally better growth status. In the higher incomegroups the grow'th status was distinctly better than in the correspond­
ing low income-groups in all regions. Generally speaking, the growth
status of infants at Calcutta was distinctly worse than those of
Bombay and Madras.
(16) It was, on the other hand, gratifying that nearly 60% to 70% ft
of infants at Bombay and Madras and 50% to 60% at Calcutta,
despite most of them living in abject poverty and under highly
unhygienic conditions, had attained in their early infancy a level of
growth comparable to that of the best international standards of
privileged North American children. The credit for this must largely
go to the salutary practice of breast-feeding still widely in vogue
among the poor.
8

I

(17) The two ends of the spectrum with respect to infant-feeding
practices were represented by Bombay and Calcutta. The Bombay
picture differed from the Calcutta picture in the following ways: (a)
more intensive and extensive breast-feeding, (b) exclusive breast­
feeding during early infancy in a much higher proportion of cases,
(c) introduction of supplements before six months in a smaller pro­
portion of infants, (d) much lower use of CM / CC as supplement, (e)
much better growth, and much lower incidence of malnutrition in
infants.
Comments

We will now address three important findings in the Study:
(A) Why do many women, who have traditionally relied on
breast-feeding for rearing their infants, and who can hardly afford
the expense of supplements, find it necessary to introduce supple­
ments to breast milk well before six months?
(B) Why do poor people who can hardly afford commercial
infant foods, and who certainly do not have the necessary facilities
for their hygienic use, go in for them?

(C) What are the factors underlying the striking differences with
respect to the level of lactation performance, use of CM/CC and
growth status of infants as between Bombay and Calcutta?
These three questions may in fact be related and the answers to
them may overlap; we will, therefore, deal with these questions
together. We may admit, at the outset, that at present we do not have
all the data necessary to permit categorical answers to these
questions.

(1) As in the case of most physiological attributes, lactation
performance may also be subject to individual variability and there
may be a ‘normal physiological range’ with respect to daily output of
breast milk. We may expect that where the health nutritional status
of the mothers is normal, even women representing the lowest ends of
the normal physiological range of lactation may be able to provide
enough breast milk to meet the full needs of the growing infant in the
early half of infancy. On the other hand, in situations where the
9

mothers are subject to severe environmental stress, dietary depriva­
tion and undernutrition, there may bean impairment of lactation. In
the case of women with lactation performance in the upper levels of
the normal range, despite reduction in output consequent on such
impairment, the output may be adequate to meet the needs of the
infants. On the other hand, in the case of those mothers already in the
lowest levels of the normal range, such impairment could affect the
output of breast milk to a point when it falls short of the levels of
adequacy needed to sustain normal growth and development of the
infant. We admit that we do not as yet have concrete evidence in
favour of this hypothesis. In this Study, we did not investigate the
actual output of breast milk. However, in the absence of clear
evidence to the contrary, the possibility that output of milk might
indeed have been inadequate in a proportion of cases cannot be ruled
out. We found many exclusively breast-fed infants showed growth­
retardation even in early infancy. Such retardation need not neces­
sarily imply inadequacy of breast milk output. It could be argued
that such growth-retardation was due to repeated episodes of infec­
tion. The fact that infants receiving supplements did not have better
growth status lends support to this argument.

Studies at the National Institute of Nutrition, Hyderabad, several
years ago, had shown that among poor undernourished women,
nutritional supplementation could increase the output of breast milk
and increase the concentration of some vitamins but had no signifi­
cant beneficial effect on protein concentration (Bibliography—53).
Many women in this Study belonged to the poorest sections subsist­
ing on around 2000 K Cal and around 40 g of protein daily. It will be
reasonable to expect that the output of their breast milk can be
significantly augmented through improvement of their diets and
nutritional supplementation. We will, however, argue that irrespec­
tive of this consideration, there is a legitimate case for programmes
designed to improve the nutritional status of nursing mothers.
(2) Mothers who believe (or who are persuaded to believe) that
their infants are not thriving on breast milk alone will look for
supplements. The choice of supplements will be naturally determined
by advice from health personnel, family members and neighbours,
the example set by privileged sections of the community and the
10

prevailing value systems. Fresh animal milk may be expected to be
the most obvious choice in early infancy. We understand tha' the
availability of fresh milk in the Calcutta and Madras regions is lower
than in Bombay; moreover, fresh milk in quantities needed for
adequate supplementation is also expensive. Health personnel are
not equipped, at present, with sufficient knowledge to offer practical
advice as to how best locally available inexpensive habitual foods of
the family can be used to supplement breast milk. Under the circum­
stances, it is not surprising that the poor go in for commercial infant
foods in the belief that these foods are so ‘nutritious', that they will do
good to their babies even if fed in small quantities (more like tonics
than foods). The current phenomenon of considerable sections of the
poor going in for these foods and stretching them for weeks on end by
feeding them in ov'erdiluted form is the result.
(3) The reasons for the striking difference between the Bombay
and Calcutta regions with respect to (a) growth status and morbidity
profile of infants, (b)Jactation performance, (c) time of introduction
of supplements, (d) use of CM/CC. can only be speculated upon. The
two major possibilities could be: (1) that environmental sanitation in
poor communities in the Calcutta region was far worse than in
Bombay, and (2) that the poor women in the Calcutta region investi­
gated in the Study were even poorer than those of Bombay; and that
they were in a much worse nutritional state and were subsisting on
much worse diets than those of Bombay and that consequently their
lactation performance was poor. The follow-up studies which we are
shortly undertaking in the two regions, will provide direct evidence
on these possibilities. As far as we are aware, this is the first time that
such a startling difference in the growth status of infants in the
different regions of the country has ever been demonstrated on such a
large scale.
In our present Study, we had unfortunately not included the
Punjab region. But there have been some excellent recent observa­
tions on lactation performance of women in Punjab. Das and her
colleagues (Bibliography—39) in Ludhiana in Punjab, had shown
conclusively that “in spite of their disadvantages of poverty, poor
diet, unhygienic surroundings and overwork” under-privileged
mothers of Punjab were able to achieve a good state of nutrition for
11

their infants through exclusively breast-feeding them for six months
in the case of 90fi of their male infants and 73% of their female
infants. On the basis of these observations these workers had con­
cluded: "From our experience we are certain that it is our duty to
teach workers not to add to the tremendous burdens of the mothers
of the under-privileged community by asking them to give anything
other than breast milk for six months. Our duty is to motivate these
mothers towards exclusive breat-feeding throughout the first six
months." The sample studied by Oas el al. above was not strictly
comparable to the samples investigated in the present Study, because
Das et al. had included in their sample "only infants who had a
favourable start, that is, full-term singletons with birth weights of 2.5
kg or more, and no congenital abnormalities and obvious birth
trauma." They had also excluded 4.8% of mothers “who had failed to
establish good lactation." Even allowing for the fact that Das et al's
sample was thus a selected one, their observations suggest that
lactation performance of the women of Punjab (even the underprivi­
leged ones) is clearly superior to that of the poor women of Calcutta
and Madras and perhaps even somewhat better than those of Bom­
bay. This is another example of regional difference in lactation
performance of women in the country*.
There is the general impression that the women (even poor
women) in the rural countryside of Punjab are much sturdier and
stronger than the w omen of the poorest communities of Calcutta and
Madras. They, like the women of Maharashtra (Bombay), do not
belong to the “rice belt" of the country -the east and the south,
where some of the worst ravages of malnutrition in the country are to
be seen. Unfortunately, we do not have precise data on the anthropo­
metric and nutritional status and dietary intakes of the nursing
mothers in these different regions, which will help us decide to what
extent regional differences in lactation performance are in fact
related to differences in the mothers’ health/nutritional status. Das
et al's observations, however, clearly show that with good antenatal
care and proper motivation, a high proportion of even under­
privileged women can successfully exclusively breast-feed their
infants for six months. Their observations indirectly underscore the
need to ensure adequate nutritional status of the mother, good
antenatal care and proper motivation so as to enable them to do so
12

We do not believe that differences between Punjab, Maharash­
tra, Bengal and Madras are of ethnic origin because within each
region we have instances of mothers who can exclusively breast-feed
their infants for six months and some who cannot.

There is evidence of faltering of growth in a proportion of breast­
fed infants in the early half of infancy; but there is also the same
evidence of such faltering even in infants receiving supplements.
Indeed, generally speaking among the poor income-groups, differen­
ces in growth status between the exclusively breast-fed and supple­
mented groups of infants within six months did not appear to be
significant. Therefore, while we cannot rule out inadequate lactation
as a factor responsible for growth faltering, it seems possible that this
may not be the major factor. Repeated infectious episodes which are
seen (though to a less extent) even in the exclusively breast-fed
infants could be the major factor. If the latter is the case, supplemen­
tation may not correct the situations but may actually aggravate it.
The theoretical benefit of early supplementation may be more than
offset by greater risks of infection, with the result that at six months,
the infant with supplementation may end up as no better, and
perhaps even worse, than the one without it. A decision as to the
timing of introduction of supplementation must be governed by an
appreciation of the total context in which the infant is being reared.
Under the circumstances, it may be prudent not to view minor
degrees of growth faltering before six months as an indication for
advising supplements. It may be the right strategy to motivate moth­
ers to continue with exclusive breast-feeding for six months but such
motivation must be accompanied by attempts to improve maternal
diets through nutritional supplementation, where necessary. If, how­
ever, growth-retardation persists, then it must be presumed that
breast milk is inadequate and supplements must be introduced.
Strategies for the promotion of wholesome
infant-feeding practices
Taking into account the socio-economic and environmental con­
ditions in which the vast bulk of our infants are being currently
reared (and will continue to be reared for at least the next two
13

decades) our National Policy with respect to ensuring health nutri­
tion of our infants must squarely rest on the strategy of. (a) promo­
tion of exclusive breast-feeding for the first six months of infancy,
(b) introduction of such supplements as fresh animal milk and a
judicious combination of food items of the habitual family dietary
such as cereals, dhal (legumes) and vegetables, after six months,
while continuing breast-feeding as long as possible, (c) promotion of
better hygiene, and cleanliness in the handling and feeding of foods
of the infant, (d) education regarding avoidance of, and care during
infections, and (e) regulating the use of commercial infant foods.
The implementation of the strategy proposed above will call for
several steps, which we briefly enumerate here.
A.

Support to mothers

(') Improvement and sustenance of maternal nutrition: The com­
placent assumption that no matter how ill-nourished the mother is
she will (and must) deliver the breast milk needed for her baby in
adequate amounts must be given up. We have, so far. largely neg­
lected what perhaps is the most important and crucial determinant of
successful breast-feeding, namely, the state of maternal nutrition; if
exclusive breast-feeding in early infancy and continued breast­
feeding for the greater part of infancy have to be ensured, we cannot
afford to neglect this aspect any more. In all “nutrition intervention”
programmes directed to infants and children, it should be the policy
that, where there is evidence of growth-retardation in the infants in
early infancy, nutrition supplements must be provided to the mother
and not to the infants and the effect on growth of the infant could be
monitored. Only if it is found that such nutritional supplementation
to the mother has not resulted in improvement of growth status of the
infant should supplements be directly offered to the infant. If this
policy is followed, the present practice of straightaway using any
evidence of growth faltering in early infancy as an excuse or justifica­
tion for introduction of CM/CC will be curbed. We welcome the
policy of offering supplements to nursing mothersduringthe first six
months of lactation that is now being followed in our I.C.D.S.
programme.
14

(2) Subsidised foods for nursing women: The Government should
earnestly consider a programme for providing at subsidised prices
such items as fresh animal milk, bread and good-quality biscuits (see
below), especially to nursing mothers belonging to the poorest
income-groups. These items taken by the mothers in addition to their
habitual diets, could help to augment the quality and quantity of
maternal diet and of breast milk. If, in consonance with our Family
Planning Policy, it is so desired, this facility may be limited to
nursing mothers for the first and second living infants only. This step
would, of course, call for considerable administrative competence.
but programmes of far greater complexity have been successfully
accomplished in other countries (the food distribution policy of
Britain during the World War 11 is only one example). The questions
here are: Do we consider this matter as of sufficient importance to
mobilise the administrative machinery and competence needed for
this purpose? Or do we wish to dismiss this as ‘a game not worth the
candle'.’
(3) Provision of facilities for breast-feeding to working mothers:
Employment of women in full-time occupations may not at present
be a major factor in influencing infant-feeding practices in the
country as a whole, for the reason that only a very small fraction of
women in low income-groups and in rural areas are engaged in
full-time occupations outside their own villages. The problem is now
largely confined to a small proportion of women in urban areas.
However, the situation could change in the next two decades with
increasing employment opportunities for women. Women in rural
areas around major cities may start commuting to their work-sites in
nearby cities in increasing numbers; the practice of breast-feeding in
early infancy will then come under great strain. Indeed this factor
would turn out to be as much a threat to breast-feed ingas the current
aggressive unethical marketing practices of baby-food manufactur­
ers. Under the pressure of their occupational needa. women will
increasingly have to turn to ‘convenience foods’ and in such a situa­
tion baby-foods may not even need “aggressive" advertisements. Any
policy for the promotion and fostering of the salutary practice of
breast-feeding must take note of this possible emerging scenario in
the field of infant-feeding within the next two decades.
15

L

There would appear to be only two major approaches towards
meeting the possible threat to breast-feeding likely to be posed by
increasing employment opportunities to women: (1) provision of
facilities to mothers for feeding their infants at work sites through the
setting up of creches at work places; this may not always be possible.
(2) extension of the duration of paid maternity leave to cover the
major part of early infancy; (the current duration of maternity leave
is too short to permit exclusive breast-feeding for the greater part of
early infancy). Such a facility may be granted to working women of
poor income-groups at least for their first and second infants. Exten­
sion of such facilities for infants of higher birth order may be viewed
as a disincentive to limitation of family size and may not be in
consonance with our current national policy.

|

The second approach may turn out to be more feasible and less
expensive. It must be remembered that the provision of creches at
work sites, in addition to expenses involved in their maintenance,
does imply permission for partial absenteeism from actual work The
balance of advantage may thus be in extending the duration of
maternity leave to cover the major part of early infancy.

(4) Education of would-be mothers: In an earlier publication
(Gopalan C„ “Home Science" And Vocational Training For Rural
Girls-A Proposal. Bull. Nut. Foundation of India 5.1.5, 1984) an
imaginative programme of education beamed to girls in rural areas
(between 12 and 20 years of age) who are on the threshold of
marriage had been suggested. Most of our girls in rural areas enter
marriage and attain motherhood with no training in mothercraft and
in total ignorance of wholesome infant and child rearing practices.
The real key to successful infant rearing is the improvement of the
knowledge and competence of mothers. They will then no longer be
easy prey to tendentious advice and advertisements. We, therefore,
reiterate the recommendation in the earlier publication referred to
above.
B. Promoting use of supplements other than commercial infants
foods

(1) Increasing the availability of animal milk in rural areas: Fresh
animal milk at reasonable prices must be available to the poor. Our
16

I

milk production policy must be such that it does not denude the rural
areas of milk in order to feed the urban elite. Milk is, by no means, an
unnecessary luxury for the poor infants; it is an essential food item
especially in the context of the fact that the only inexpensive supple­
ments that the poor can afford for their infants are cereals and to a
certain extent pulses (these latter are getting increasingly beyond the
reach of the poor). We will be doing a great deal to discourage the use
of expensive commercial infant foods by the poor by making fresh
animal milk easily available to them at reasonable prices.

(2) Use of inexpensive food items of the family diet: Inexpensive
food items of the habitual family dietaries can be effectively used in
judicious combinations as supplements for infants. Mothers should
be encouraged to use these food items—like 'chapaties '(wheat bread)
dipped in hot tea (in Punjab) or rice, dhal (pulses) and vegetables
mashed (in the rice belt). Health personnel must be provided manu­
als containing information regarding suitable supplements for
infants based on local food items, which the mothers could use.
When practical advice based on local conditions is offered (such
advice is not offered at present) they may find acceptance. Vague
advice will be of no value. In the absence of practical advice, mothers
now turn to commercial infant foods. Home Science Colleges att­
ached to Agricultural Universities in different States may be encour­
aged to prepare such manuals suitable for different regions.
(3) The training of health personnel: The health personnel,
including doctors, require better practical training in the promotion
of wholesome and feasible infant-feeding practices among poor com­
munities than what they are at present receiving. When confronted
by a poor woman seeking advice as to what she should feed to her
baby which is not thriving on her breast milk, most of them today are
in no position to give realistic advice. The theoretical knowledge
which they have gained during their training proves to be of no avail
when they are confronted with real-life situations. Under such cir­
cumstances, they often advise commercial infant foods—an advice
which is not time-consuming and which is in consonance with what
the affluent are practising. If health personnel should not unwittingly
become the allies of baby food manufacturers due to such ignorance.
we must improve their training and such training should be tailored
17

to suit local situations and local dietary habits. The fact that some
health personnel advise commercial foods to infants of families they
come into contact with is, no doubt, a matter of concern. But
fortunately the infants so advised, at present, constitute a tiny frac­
tion of the population. What is more disturbing is that health person­
nel do not advise the non-use of commercial infant foods to the vast
bulk of the rural poor, for the reason that (a) they do not reach them
and (b)they are not equipped and trained to suggest practical and
feasible alternatives to CM/CC under the real-life conditions in the
field.

(4) Improvement of quality of biscuits in village shops: We have
found in our Study that there was extensive use of biscuits in infant­
feeding especially among the poorest sections of the population in
Madras and Bombay and to a less extent at Calcutta. The biscuits
used were from the village shops, and were the products of smallscale industry. (The good, elegant, highly priced biscuits of the
large-scale manufacturers are of course for the urban elite and well
beyond the reach of the rural poor). At present there is absolutely no
effort at quality control and at ensuring reasonable nutritive value of
these biscuits, which are in such wide use among the poor; the poor
arc not getting their money’s worth. The otgauised large-scale sector
in biscuit manufacture is apparently not interested in transfer of
technology to the small-scale sector which caters to the poor infants
and children of urban slumsand villages. The Government must look
into this question. By improving the quality and nutritive value of’
biscuits and offering them at subsidised rates to pregnant and nurs­
ing women and infants and children of the poor, we will be utilising a
ready-made channel which is already in wide use in the countryside.
for the betterment of the nutritional status of the poor. It must be
remembered that the poor also stand in need of ready-to-eat ‘conven­
ience foods’, which will help save time, energy and fuel and which will
be a supplement to the family diet. There is no danger of biscuits
displacing breast-milk (as CM/CC could) because they will be used
only as supplements mostly in the latter half of infancy just as they
are now being widely used.

IK

C. Augmenting health services and improving environmental
sanitation

(1) Increasing the outreach of health services: If infant morbidity
has to be reduced and wholesome infant-feeding practices are to be
promoted, we have to greatly increase the out-reach of our health
services. At present, the majority of the rural poor do not have access
to basic health care and so health personnel are in no position to
influence infant-feeding practices or to mitigate infant morbidity in
most of our rural areas. It is only when health services reach down to
our villages that a programme of monitoring growth (and nutritional
status) of infants and children would become possible and the effects
of morbidity can be mitigated. The control of morbidity is only next
in importance to promotion of breast-feeding in ensuring good
nutrition for the infant, and health personnel can make a significant
contribution in this regard.
(2) Safe water supply and sanitation: If we have to reduce the
present high prevalence of morbidity in infancy and childhood, we
must ensure basic sanitary facilities in our villages. In particular, safe
water supply is an essential requisite. In the absence of safe water,
any supplement could become a source of infection. It is unfortunate
that a majority of our rural population do not have access to safe
water supply.
D.

Regulating use of commercial infant foods

(1) Education regarding superiority of breast milk over commer­
cial infant foods: The urban elite constitute a tiny fraction of our
population, but they are the trend-setters whom the poor envy and
wish to emulate. The elite must be made fully aware of the over­
whelming new evidence pointing to the clear superiority of breast
milk over all baby foods; a vigorous movement for return to tradi­
tional breast-feeding must be initiated among the urban elite, and
maintained with sustained tempo. The prestige and aura that now
surround CM/CC must be dispelled. The poor will be suspicious of
advice which smacks of double standards. If programmes to discour­
age commercial infant foods among the poor should command
credibility and make headway, they must be accompanied by parallel
19

movements among the rich—somewhat on the lines of the movement
in USA and Europe. We must ensure that CM >CC are not promoted
in a manner which suggests that they are substitutes to breast milk
not only among the poor but also among the affluent. At most they
could be presented as just one of the possible supplements to breast
milk. In that case the disadvantages and risks arising from their use by
poor communities because of economic or environmental con­
straints must be pointed out. The poorshould not be lured into using
them by planting in them the belief that these foods have unique and
precious nutritional properties, and will, therefore, benefit their
infants in a manner which no other food within their reach can do.

(2) Implementation of the new Code: The Code recently adopted
by the Government of India is good so far as it goes. Much would,
however, depend on how it is implemented. We are distressed to find
that despite the Code, some brands of commercial infant foods are
still being promoted in a manner which suggests that the letter of the
Code is being observed (in order to keep within law) but not the
spirit. Multi-national baby food manufacturers, goaded by the profit
motive, may not be expected to summon the concern and care for the
poor necessary to avoid unethical promotion of their products; it is,
therefore, the responsibility and duty of the indigenous (national)
baby food manufacturer to set the highest standards in this regard
and thus show' the way. If indigenous manufacturers observe the
highest standards of ethics, it will be easier for the Government to
deal firmly with errant multi-nationals. A truly effective machinery
for ensuring the rigid observance of the Code must be set up. Other­
wise the entire exercise of drawing up the Code will become a
mockery much like the statutory warning on the cigarette packets.
The implementation of the Code cannot be left to government agen­
cies alone (they could also sometimes become vulnerable). There
must be a people’s movement to ensure that the traditional practice
ol breast-feeding not get eroded; consumer protection societies,
voluntary' agencies, the media and the enlightened lay public must
take the lead and perform their watchdog duties in this regard.
(3) Enlisting support of the medical profession: The impressions
that medical practitioners, paediatricians and health professionals in
general tend to advise commercial infant foods too readily, and that
20

there could be an unholy alliance between some of them and baby
food manufacturers, have tarnished the fair name of the profession.
The latter allegation may, perhaps, be a bit too sweeping. However,
without bothering about ‘impressions’, in the interests of child
health, nutrition, neonatologists and paediatricians must take the
lead in spearheading movements for fostering and promoting the
traditional practice of breast-feeding. It is their participation that
will lend such movements prestige and authenticity. We are of the
firm view that the over-whelming majority of the medical profession
are public-spirited, and dedicated to the cause of promotion of
national health.

(4) Changing the hospital culture: The finding that delivery in
hospitals, favouis use of commercial infant foods is distressing. That
in some hospitals at Bombay, infants were introduced to bottles of
commercial milk immediately after birth, even before their mothers
had had a chance to put them to breast, is shocking. Fortunately, we
found that this practice was not widespread. Government hospitals
are teaching centres where medical students and other health profes­
sionals are trained. The traditions and the precedents they set must
be exemplary and designed to promote health. Consumer societies
headed by enlightened paediatricians must brihg such deleterious
practices in our hospitals to public notice and governmental atten­
tion. We do not suggest punitive witch-hunts but a constructive
movement designed to eradicate current unhealthy and unethical
practices.
(5) Placing commercial infant foods in proper perspective: It will
be bad strategy to resort to overkill by painting baby foods as
‘poisons’. Exaggerated statements and extreme positions may prove
counter-productive. These foods have a place as just one of several
possible supplements to breast milk in late infancy among those who
have the means to afford them and the facilities to use these hygienically. But the poor must be disabused of the impression that these
foods are unique, essential and could confer benefits which other
much less expensive supplements cannot.
The potential harm that these-foods can cause when unhygienically used, and the little nutritional benefit which they can provide
21

when used in the small quantities which alone the poor can afford,
must be highlighted by health professionals so that the poor are
‘weaned away’ from these foods.
The state of our infants and children is the true test of the state of
our ‘development’; it is also the most important determinant of our
future. No national programme can be more important than the ones
directed towards the betterment of their health and nutrition.

22

Appendix
Why breast milk is better than formula baby foods
By
C. Gopalan
This paper was written by the author at the request of the Ministry of Social
Welfare, Government of India, for use by the Ministry. The Ministry was keen that the
latest information pointing to the unique properties of human milk should be widely
disseminated to the enlightened lay public. This article was beamed to the urban
elite—the trendsetters. Il has been reproduced here as it appeared relevant to the
present Study.

In the long history of mankind, spread over several centuries, the
practice of bottle-feeding of infants with milk formulas (baby foods)
is a very recent development. This had its origin in the affluent
countries of the industralised West barely 60 years ago. It is doubtful
if this practice could have grown to its present dimensions if all that
we know today about the unique and inimitable qualities of breast
milk was known earlier.
Recent findings

Why breast-feed? Recent researches have thrown a great deal of
new light on the chemical and biological properties of breast milk,
and have clearly established its superiority over all milk formulas in
the promotion of growth, health and development of children.
Unlik^.milk formula foods which are inert and have a fixed composi­
tion, breast milk is a dynamic “living fluid,” specially adapted to the
infant, its composition and output changing with the changing needs
of the infant. There are changes in its composition over a period of
time, during the day, and indeed even during the course of a single
feed. For example, the fat content of breast milk is low at the start of
a feed and gradually builds up to its peak value towards the end.
Colostrum, secreted during the first five days after delivery, has a
23

different composition from that of mature milk. It is lower in fat but
richer in proteins and has a higher concentration of antibodies which
protect against infections. It is also a richer source of zinc and
vitamin A (which can be stored in the infant’s liver). Zinc and vitamin
A are now known to have profound influence on immunological
mechanisms concerned in resistance to infections. By not putting the
infant to the breast immediately after delivery, the infant is denied
these benefits.

Breast milk gradually attains its ‘mature’ state with respect to
composition and output by the fourth to the sixth week after deliv­
ery. The daily output of milk varies depending on the frequency of
the feeds and the force of sucking by the infant: thus, within limits,
the more hungry the infant the greater the output. The proteins of
breast-milk, unlike those of formula foods, contain a relatively low
proportion of casein, resulting in softer curd, easier digestibility and
less likelihood of constipation; the lactose is high and helps to
maintain low electrolyte concentration; the fat contains high levels of
essential unsaturated fatty acids (linoleic acid), and also provides
vitamin E (also concerned in defence against infections). The cal­
cium, iron and zinc in breast milk are much better absorbed than the
same elements in milk formulas. The sodium content is lower; this is
important because the kidneys of the new-born cannot deal with a
heavy load of solute. The stools of the breast-fed infant, unlike of
those on baby foods, are acidic due to high concentration of lacto­
bacilli, and this helps to inhibit fungal infection. Thus'the chemical
composition of breast milk, unlike that of baby foods, is specially
adapted to the physiology of the infant.
Breast milk contains a wide range of anti-infective substances
including white cells (lymphocytes) and antibodies (secretory immu­
noglobulins). The latter protect the absorbing surfaces of the infant’s
intestines (intestinal mucosa) against such deadly bacterial infections
as E. Coli, Shigella and Salmonella, and Rota Virus infections,
which are mostly responsible for infantile diarrhoeas and deaths.
There are also antibodies against polio virus and influenza virus,
certain other respiratory (lung) viruses, and against organisms con­
cerned in meningitis and middle-ear disease (ottitis media). The
antibodies in breast milk are those produced in response to infections
24

which the mother is exposed to in her environment. Thus the profile
of antibodies in a mother’s milk is specifically designed to protect her
infant against the infections prevalent in its given environment —
another example of how the composition of breast milk is tailored to
the special needs of the infant. Formula foods do not contain these
protective antibodies; and not ail the money in the world can buy
them
The current Indian scene

Fortunately, in India today the great majority of our rural
women have not. as yet. discarded breast-feeding, in fact, they
generally breast-feed their infants for durations extending to 18
months or more. This is the brightest feature of India’s current
nutrition scene, and this would, incidentally, show that "lactation
failure” in the affluent is largely due to psychological rather than
organic causes. The problems of infant mortality and protein-calorie
malnutrition will be far worse than what they are today but for this
valuable asset. While commercial baby foods have not as yet, made
significant in-roads into the interior rural areas of the country, the
poor and middle-incomc-groups in the cities, urban slums, small
towns and in the periurban rural areas have apparently not been so
fortunate and have not been spared.
in the conditions prevailingamong our poor communities, exclu­
sive breast-feeding for the first six months yields optimal results with
regard to growth and development. As a general rule, supplements
need to be introduced only after six months. The supplements can
consist of the habitual food items of the family—cereals, pulses and
vegetables prepared and fed appropriately and hygienically, and, if
necessary, top-feed of cow’s milk. Even after such supplements arc
introduced, breast-feeding must continue as long as possible. Expe­
rience in Ludhiana has shown that with such a regimen normal
growth can be ensured even in the poorest children.

There are several myths about breast-feeding and formula foods
prevalent among the affluent sections of our society. One such is the
belief that breast-feeding is “not good for the figure”. Actually
breast-feeding through helping the woman to shed the extra fat she
25

stores during pregnancy, will help improve her figure. Another myth
is that formula foods contain special substances which breast milk
does not, and so build bonnier babies; indeed, as mentioned earlier,
formula foods cannot even fully substitute for breast milk, let alone
excel it.

It is not surprising, therefore, that diarrhoeas, respiratory infec­
tions and deaths are far less common in breast-fed infants than in the
bottle-fed. A study in Haryana showed that the incidence of diar­
rhoeas in bottle-fed babies was three times higher than in the breast­
fed. Dehydration resulting from diarrhoea, was also more severe in
the bottle-fed infants. A study from another developing country
showed that bottle-fed infants were hospitalised with infectious dis­
eases ten times more often, and spent ten times more time in a
hospital in their first year than fully breast-fed infants. Even in a
developed country (USA), it has been reported that of 107 infants
belonging to the middle-income-group admitted to the hospital with
acute diarrhoea in a given period, only one infant was breast-fed. Ina
London hospital, while 14% of the infants in the community served
by the hospital were being breast-fed, only two of 608 infants admit­
ted to the hospital with diarrhoea were breastfed. The protective
effect of breast-milk against infections both in poor and affluent
societies, has thus been well documented. In fact attempts have even
been made to prevent and treat outbreaks of diarrhoeas in bottle-fed
infants by feeding them breast milk. Breast milk also has antibodies
which protect the infant against allergy, again by insulating the
intestinal mucosa from the allergens (agents of allergy) in the gut.
Quality of breast milk
What is gratifying in our context is that, with respect to the
concentration of protein, fat, lactose, calcium, and anti-infective and
anti-allergic antibodies, there are no differences between the breast
milk of poor and affluent mothers. The quantity and concentration
of some vitamins in the breast milk of poor mothers, can. however,
be further improved by improving the maternal diets. The cost of
such improvement which will improve the health and nutritional
status of both the mother and her infant will be a very small fraction
of the cost of bottle-feeding baby foods.
26

Breast-feeding also promotes better ‘bonding’ (attachment
between mother and infant) conducive to the psychological and
emotional development of the child. A recent WHO/UNICEF
report states, that breast-fed infants generally show more bodily
activity and tend to start walking earlier. Breast-feeding is a natural
(though not an absolutely reliable) form of contraception. The more
frequent and intense the breast-feeding the greater the contraceptive
protection, brought about through increased levels in the maternal
blood of the hormone, prolactin, which inhibits ovulation and
resumption of menstruation. The WHO/ UNICEF report referred to
earlier, mentions that breast-feeding alone, in the absence of contra­
ceptives, could increase the interval between child-births by Five to 10
months. In a middle income-group of Indian women, only 62% of
those who were breast-feeding their infants had resumed menstrua­
tion by eight months after delivery as against 100%of those who were
bottle-feeding their infants.

Economic implication

Simple arithmetic will show that with the current levels of income
and present cost of baby foods, no working-class family can afford
bottle-feeding with baby foods. The same is true of most families in
the middle-income-group. Such families when they are persuaded to
use baby foods, resort to overdilution in order to stretch the small
quantities they can afford to the maximum extent possible. With the
shortage of fuel, clean water and storage facilities, they cannot ensure
strict hygienic conditions in preparation and feeding. Undernutrition
and infection of the infant are the inevitable results. Even for affluent
mothers, baby foods may be recommended only if breast-feeding has
been attempted and found to have failed. However, some health
professionals all too readily assume action failure even when it does
not genuinely exist, and instead of reassuring the mothers, advise
bottle-feeding with milk formulas. This has given rise to the unfortu­
nate impression of an unholy alliance between some health profes­
sionals and baby food manufacturers. Bottle-fed babies of even
affluent families do not escape diarrhoeas and dysenteries, partly
because ayahs and servants are entrusted with the feeding. In recent
years, several deleterious effects of baby foods have been reported
27

such as obesity, cow’s milk allergy, metabolic stress in premature
babies and colitis.

With increasing recognition of the clear superiority of breast milk
and greater awareness of possible deleterious effects of baby foods,
there are now active movements in developed countries urging return
to breast-feeding. As a result, more and more women in those
countries are now breast-feeding their infants. Working women even
express their breast milk into sterilised cups or bottles so that the
baby can have feeds even in the absence of the mother. This, together
with the declining birth rates in those countries poses the threat of
shrinking markets for baby foods there. The manufacturers are
therefore increasingly turning their attention to the poor developing
countries of Asia and Africa to expand their markets, much to the
detriment of infant nutrition in these countries. The substitution of
breast-feeding by bottle-feeding with baby foods at the present stage
of our national development, with vast sections of our population
still afflicted with poverty, illiteracy and poor sanitation, could prove
truly catastrophic. Codes for regulating the marketing and advertise­
ments of baby foods drawn up by international and national agencies
will have only very limited value. Commercial firms promoting their
different brands of baby food, employ the slogan “ breast milk is
best” as the opening gambit in their advertisement campaign in order
to conform to ‘codes’and ‘regulations’: but, after thus quickly getting
over the formal ritual, business generally goes on as usual. Slogans
and codes could easily degenerate into a farce, unless backed and
supported by practical steps. We may briefly consider some of these
steps.

Practical steps
The government, apart from drawing up codes, must enunciate a
clear policy on infant nutrition, indicating its determination (a) to
promote and foster the breast-feeding practice and to take all
appropriate measures for this purpose, (b) to prevent undue expan­
sion of production and import of baby foods and to institute string­
ent measures to check unethical practices in the marketing and
advertisement of these foods. This could be part of a comprehensive
national nutrition policy.
28

In pursuance of such a policy: (1)government should imme­
diately set up an independent statutory commission vested with
sufficient authority and powers to monitor the production, import,
marketing, advertisement and sales of all baby foods, and to check
undue expansion of production and import of baby foodsand uneth­
ical promotion, marketing and sales practices likely to erode the
practice of breast-feeding. Such a commission could be composed of
independent and public sprited paediatricians, eminent social scient­
ists, representatives of voluntary organisations concerned with prob­
lems of child health and nutrition, consumer associations and
women’s organisations.
(2) The media, especially the All India Radio and Doordarshan
should stop all advertisements of commercial baby foodsand cereal
foods. All India Radio programmes reach down to the villages and
the villager can hardly distinguish between a commercial advertise­
ment and authentic governmental pronouncement. Instead of propa­
gating such commercial advertisement of baby foods, these agencies
should organise frequent programmes for propagating and promot­
ing breast-feeding and for actively dissuading the public from dis­
carding breast-feeding in preference to bottle-feeding of baby foods.
(3) With more women seeking employment outside their homes
and with urban migration, the practice of breast-feeding will be put
to severe strain in the years ahead. In all our employment pro­
grammes involving women, there must be built-in provisions and
facilities for preservation and promotion of the breast-feeding practi­
ces. Creches must be provided at work-sites and women must be
allowed time during working hours to breast-feed their infants. The
government may seriously consider increasing maternity leave benef­
its from the present three months to six months for the first and the
second living child (only) in the case of mothers of the weaker
sections who continue to exclusively breast-feed their infants for six
months.

(4) In undergraduate medical education, in the training of all
categories of health personnel and, most importantly, in the training
of paediatricians and obstetricians, much greater emphasis than at
present, must be laid on the overriding need to preserve and protect
29

the breast-feeding practices. In the ultimate analysis, it is the health
professionals who have to play the major role in advising and encou­
raging mothers to breast-feed their infants. Such advice must always
be accompanied by practical suggestions for improving the diets of
the nursing mothers in order to sustain their health and nutrition.
Promotion of maternal nutrition must be an integral part of all
programmes for the promotion of breast-feeding. All this requires
adequate training of health professionals at the practical level; at
present the training in this regard is wholly inadequate.

(5) However we should not depend on goverment efforts alone.
What we need is a people’s movement, in which vigilant voluntary
organisations, enlightened citizens, educated women and the press
must join hands. It is only when public opinion is thus created and
people are alerted, that governmental measures can succeed.
(6) Those who extol the value of breast milk rarely speak of the
poor status and low dignity now being accorded to women in our
society. Women will normally wish to breast-feed their infants for as
long as feasible, because of the emotional satisfaction they would
derive therefrom; but they should not be faced with the agonising
choice of either pursuing the interests and vocations or of breast­
feeding their infants. We need to evolve a policy which will enable
them to do both. The development of such a policy is the real
challenge to all those interested in national development, women’s
uplift and child nutrition.

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