Bovine Milk Usage and Feeding Practices for Infants in India

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Original Article

Bovine Milk Usage and Feeding Practices for Infants in India Meha Mayuri1, Vivek Garg2, Chandan Mukherji3, Divya Aggarwal4, *Sanjeev Ganguly5 1

Scientific Information Analyst, 2Manager Medico Marketing, 3Head of Consumer and Customer Insights, 4Consumer Insights Manager, 5Head, Medical and Scientific Affairs, Nestlé India Limited, Gurgaon, Haryana, India

Abstract Background: Milk and dairy products from animal sources (cow’s milk or buffalo’s milk) are an important part of Indian diet and its consumption starts at an early age. Objective: The purpose of this study is to understand the processing, storage and modifications carried out before bovine milk is fed to the infants and compare it with recommendations by Health Care Professionals (HCPs). Materials and Methods: The study involved assessments involving HCPs and mothers of children below 1 year of age through both qualitative and quantitative methods. Feeding recommendations by HCPs were assessed through a quantitative method. Results: The children are commonly initiated on bovine milk post 3 months of age. The milk is not covered while boiling in 70% cases and boiled at suboptimal temperature (moderate: 62% or low: 31%). Half of the families store milk outside refrigerators openly in the kitchen or rooms. The milk is modified in the majority of cases (81%) before being fed. Modification of the milk was often done with sugar (85%), followed by water (49%), biscuits, fennel seeds, cardamom or infant cereals before feeding the baby. Addition of water was more prevalent among mothers of infants between 3 and 6 months. HCPs do not advise consumption of bovine milk by infants unless there is no other option available. Conclusion: A clear gap exists between recommended and actual practices for infant feeding in India. There is a huge opportunity to educate mothers on importance of breast feeding and benefits of implementing appropriate processing, storage, and consumption practices of bovine milk.

Key words: Bovine milk, Buffalo’s milk, Cow’s milk, Feeding practices, Infant feeding

Introduction Milk and dairy products from animal sources (cow’s milk or buffalo’s milk) are an important part of Indian diet and its consumption starts at an early age. It is reported that 15% of infants below 6 months of age receive milk from other sources along with breast milk.1 World Health Organization (WHO) recommends *Corresponding Author: Dr. Sanjeev Ganguly, Head, Medical and Scientific Affairs, Nestlé India Ltd., Nestlé House, Jacaranda Marg, ‘M’ Block, DLF City, Phase II, Gurgaon 122002-05, Haryana, India. E-mail: [email protected]

Access this article online Website: www.ijph.in DOI: 10.4103/0019-557X.96982 PMID: ***

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exclusive breastfeeding for infants up to 6 months of age continued breastfeeding up to 2 years or beyond.2 Feeding practices in infants differ widely due to socioeconomic practices and false perceptions like dilution of milk (from animal sources) for easy digestion.3 There is paucity of data to evaluate specific feeding practices that are prevalent in general population. Further, many of the practices pertaining to dilution, storage conditions, and addition of condiments have a bearing on the nutritional as well as microbiological quality of milk.4,5 The data with respect to practices involved in handling of the bovine milk in household are also lacking. To understand better the common household practices of processing, storage and modifications carried out before consumption of bovine milk in infants, this survey was conducted to analyze the bovine milk usage practices in India. The study also assessed difference in actual feeding practices with recommendations by Health Care Professionals (HCPs).

Materials and Methods This research study has been conducted independently by Indian Journal of Public Health, Volume 56, Issue 1, January-March, 2012

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TNS India Pvt. Ltd. on behalf of Nestlé India Pvt. Ltd. TNS India decided on research methodology (including choice of centers, sample size across centers, reporting criteria, etc.). This was a community based study and the data collection for this research was conducted during the period October 2009 to November 2009. The study involved quantitative and qualitative analysis of milk feeding practices from mothers and HCPs. Eight centers from different states across four zones (North, East, South, and West) in India with equal representation of one metro and one mini-metro city/town in each zone was selected for the study. The centers included in the research were: Delhi and Ludhiana (Punjab) in North; Kolkata (West Bengal) and Patna (Bihar) in East; Mumbai (Maharashtra) and Nagpur (Maharashtra) in West; and Chennai (Tamil Nadu) and Cochin (Kerala) in South. All mothers who participated in this study had infants in the age group of 0–12 months. An equal representation of infants in the age group of 0–6 month and 7–12 month was maintained across all the centers. The participants in each group belonged to different socioeconomic classes (SEC) A, B and C based on parameters defined in Table 1. Indian population has been classified under 8 SEC grades (A1 to E2) by Market Research Society of India (MRSI) on the basis of two parameters: Occupation and Education of the chief wage earner (Head) of the households. The distribution of the socioeconomic group was similar across all centers [Table 2]. Further, representation from both working

and nonworking mothers were included to ensure the reporting of feeding practices across categories. Mothers feeding their infants only cow’s or buffalo’s milk or both including other milk substitutes were included in the study.

Quantitative Assessment Data were included from 800 respondents for the quantitative analysis. A statistically significant sample size for a set of homogenous set of respondents is 30. Considering dropouts a higher sample size of 50 respondents was included. Since in each centre, the participants belonged to two homogenous groups (infants with 0–6 months of age and 7–12 months of age), at each centre 100 respondents were included leading to a total sample size of 800 respondents from eight centers. Mothers were interviewed to obtain information on milk feeding practices. Mothers were selected using random sampling methodology. Starting points (SP) were chosen randomly from each centre using an electoral method. At each starting point, using the right hand rule, the interviewer went to the house that was to the right and skipped 2 houses after every successful interview. Faceto-face interview using a well-structured questionnaire was conducted. Interviews were recorded verbatim by research associates. All interactions were held in the local language of the respondents. Information was obtained on the type of milk purchased, type, and quantity of milk feeds given to the infants and the entire storage,

Table 1: Socioeconomic criteria Education

Illiterate

Occupation Unskilled workers Skilled workers Petty traders Shop owners Businessmen/Industrialist with no. of employees None 1–9 10+ Self-employed professionals Clerical/salesmen Supervisory level Officers/executives Junior Officer/executives Middle/senior

School up to School 5–9 4 years years

SSC/HSC

Some Graduate/postcollege but graduatenot graduate general

Graduate / post-graduateprofessional

E2 E2 E2 D

E2 E1 D D

E1 D D C

D C C B2

D C C B1

D B2 B2 A2

D B2 B2 A2

D C B1 D D D

C B2 B1 D D D

B2 B2 A2 D D C

B1 B1 A2 B2 C C

A2 A2 A1 B1 B2 B2

A2 A1 A1 A2 B1 B1

A1 A1 A1 A1 B1 A2

C

C

C

B2

B1

A2

A2

B1

B1

B1

B1

A2

A1

A1

Source: “Harmonization of Demographics: A Manual for Research Agencies and Users” – Market Research Society of India 1989

Indian Journal of Public Health, Volume 56, Issue 1, January-March, 2012


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Table 2: Participant characteristics Centers

Delhi (N)

Quantitative phase age wise distribution Age of infants 0–6 months 7–12 months Total Socioeconomic distribution SEC SEC A SEC B SEC C Total Qualitative phase FGDs (N (SEC)) 0–6 months 7–12 months Total DI (N (SEC)) 0–6 months

Kolkata (N)

Patna (N)

50 50 100

50 50 100

50 50 100

50 50 100

50 50 100

50 50 100

50 50 100

50 50 100

38 36 26 100

38 32 30 100

24 39 37 100

19 32 49 100

21 30 49 100

23 31 46 100

18 32 50 100

25 39 36 100

1 (A) 1 1 (C)

1 (A) 1 1 (B) 1 (C)

1 5

2 5

1 (B) 1 1 (C) 1 (A)

7–12 months Total HCPs (N)

Ludhiana (N) Mumbai (N) Nagpur (N) Chennai (N) Cochin (N)

2 5

1 (B) 1 (A) 2 5

1 (B) 1 (A) 1 (C) 3 5

1 (A) 1 (C) 2 5

1 (A) 1 (C) 1 (B) 3 5

1 (C) 1 1 (B)

1 5

N = Number of respondents; SEC = socioeconomic class; FDG = focused group discussion; DI = in depth interview

processing, modification, and consumption procedures. The variables analyzed in the quantitative phase were: (1) purchase and storage practices adopted by mothers; (2) methods of cow’s/buffalo’s milk modification in terms of treatment and addition of supplements; (3) effect of infant’s age on the method of modification of cow’s or buffalo’s milk.

Qualitative Assessment In the qualitative phase, data from 20 mothers and 40 HCPs were included. From each centre, five HCPs participated in the research. Of the total, 60 interactions carried out in the qualitative phase, there were four focused group discussions and 16 in-depth interviews with mothers and 40 in-depth interviews with HCPs [Table 2]. Focused group discussions allowed exchange of ideas and viewpoints and helped gain a wider understanding of differing viewpoints on the usage of cow’s or buffalo’s milk. In-depth interviews helped in obtaining detailed information on the process of milkfeeding practices. HCPs included in the analysis were pediatricians with more than 5 years of work experience in renowned hospitals and they were interviewed. From mothers perspective, the parameters observed were: (1) triggers and barriers towards adoption of cow’s/ buffalo’s milk for the infants; (2) modification of milk and the reason for modification. The parameters assessed from HCPs perspective were (1) recommendations for feeding cow’s/buffalo’s milk to the infants; (2) type of

milk recommended; (3) recommendation for quantity of milk to be fed, and (4) modification required in the milk before feeding. Overall the following parameters were analyzed using the variables from quantitative and qualitative phase: (1) the reason mothers feed cow’s/buffalo’s milk to their infants, (2) the methods involved in feeding, (3) the gap between HCP’s recommendation and actual practice of usage and processing of cow’s or buffalo’s milk.

Results Quantitative Assessment Age of initiation of bovine milk: In this study, the children on an average are initiated on bovine milk post 3 months of age although mother’s milk has a higher stomach share (6 out of total 8 feeds per day) as compared to other forms of milk. In the North region, the child is started on bovine milk as early as 2.5 months of age. Initiation of bovine milk feeding to infants has been also reported to be relatively early in SEC A. Purchase practices: Overall, loose cow milk (28%) and single toned packet milk (28%) were mostly purchased followed by loose buffalo milk (15%), full cream packet milk (14%), skimmed milk (8%), double toned packet milk (6%), and token milk (1%). A large difference was observed across the regions with respect to the type of milk purchased. In North, loose buffalo milk (49%)


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Mayuri M, et al.: Bovine Milk Usage and Infant Feeding Practices

was consumed more whereas in East, cow’s milk (65%) consumption was highest. In West, packaged milk was consumed in more quantity (full cream packet milk – 27% and skimmed/light packet milk – 22%) as compared to cow’s milk (27%) and in South, single toned packaged milk was purchased more (84%). It was observed that milk has dual usage especially in families with infants between the ages of 0 and 6 months. A specific type of milk was bought for the infant(s). On an average 61% of the infants were given bovine milk. In most cases, loose cow’s milk was bought for infants while regular vendor’s/ packet milk was bought for rest of the family. Both types of milk are processed and stored separately. A regional difference was also observed with the quantity of milk purchased; more quantity of milk was purchased in North (2.3 L) and among SEC A (1.6 L) and least in South (0.74 L) and SEC C (0.98 L) [Table 3]. Most of the families reported consuming the milk on the same day, if any previous day’s milk was left it is used for consumption by adults and is never given to infants.

refrigerator (50.4%), while other families store it openly in the kitchen or rooms (49.6%). As the milk is bought mainly during the daytime, it is stored for an average of 7 h. Post boiling, 45% of the mothers leave the milk in a room/kitchen to bring the temperature of the milk suitable for baby’s feed. Only 24% of mothers reported re-heating or re-boiling milk just before feeding the infant [Table 4]. Re-boiling of milk is more frequent in SEC C due to unavailability of a suitable storage system. Also, the milk is heated more in summers and less in winters as milk tends to get spoiled in summers earlier. The utensils are mostly cleaned by boiling in the case of feeder bottle (44%) or rinsed with soap and water (42%). In the remaining cases, the utensils are either rinsed with water only or even used as such. Consumption behavior: The majority of mothers (62%) reported giving stored milk to their infants whereas the others (38%) gave fresh milk to their infants. No specific trend was noticed in consumption quantity during the day. A mixed use of different utensils is observed for either preparing the feed or feeding the infant. Commonly used utensils for preparing the feed included bowl (34%) and pan (32%) in which the milk is warmed or boiled, followed by a feeder bottle (23%) and a tumbler (12%). However, for feeding the baby, a feeder bottle was used in 58%, a bowl and a spoon in 32% and a tumbler in 10% of the cases [Table 4]. If milk was leftover during a particular feed, it’s very unlikely to be given back to infants for a later feed (4.62%); it is either discarded (50%) or consumed by some other family members (43%).

Processing and storage practices: Cow’s or buffalo’s milk is processed as soon as it reaches home in 93.3% of the cases. On an average 0.8 L of milk is boiled at one time. Dilution of the milk prior to boiling was undertaken by 49% of the mothers. On an average, 144 mL of water is added to the milk (average of 0.8 L). The milk is not covered while boiling in 70% of the cases. The milk is boiled at either moderate (62%) or low (31%) flame. After boiling, the milk is stored in different utensils for infants only if the milk bought is specific for the infants. In most cases, however, the same utensil was used for storing milk for family and infants. As far as storage is concerned, only half of the families store milk in the

Modification behavior: The milk is modified in the

Table 3: Type, frequency and quantity of milk purchased Type of milk purchased (% of people) All Zones N Loose cow milk (%) Single toned packet milk (%) Loose buffalo milk (%) Full cream packet milk (%) Skimmed/light packet milk (%) Double toned packet milk (%) Token milk (%) Frequency and quantity of milk purchased No. of times purchased Quantity purchased (L)

Town Class

SEC

All

North

West

Metro

Non-metro

A

B

C

200 13 11 49 19 – 5 4

200 27 9 8 27 22 7 –

South 200 6 84 1 7 – 1 –

East

800 28 28 15 14 8 6 1

200 65 8 1 2 9 13 1

14 33 11 13 15 11 2

41 24 18 15 – 2 –

30 24 18 14 8 6 1

27 28 16 14 8 6 2

27 32 12 13 8 8 1

1.12 1.27

1.13 2.30

1.02 1.00

1.19 0.74

1.13 1.07

1.13 1.27

1.11 1.28

1.12 1.64

1.10 1.30

1.13 0.98

Abbreviations: N, Number of respondents; SEC, socioeconomic class.



majority of cases (81%) before being fed. In this study, addition of water was observed before (31%) or during milk treatment (37%) or just before feeding (25%). Modification (addition of supplements) is done depending on the age of infant. Addition of water is more prevalent among mothers of infants between 3 and 6 months. Modification is often done with sugar (85%), followed by water, biscuits, fennel seeds, cardamom or infant cereals before feeding the baby [Table 5]. Among those who add sugar, they are likely to add more than one spoon on an average. Sugar is more likely to be added just before feed. Modifications are done primarily to make the milk easier to digest for infants and sometimes the modification is done for the entire family of the infant is above 9 months of age. The general trend noticed is that the milk packet is washed, or 1 glass of water is added per 1 liter of milk.

Qualitative Assessment Health care professionals’ advice: It was observed that HCPs do not advise consumption of cow’s or buffalo’s milk by infants unless there is no other option available. However, the commonly given advice includes: • Use pasteurized milk as it is more hygienic than loose milk • Milk should be boiled completely. Water and milk should be added in the ratio of 1:3 for young babies (1–2 months), dilution is not required for older babies above 3 months of age.

•

• •

•

Milk should be cooled down at room temperature and fed with spoon and bowl instead of feeding bottle. Hygiene should be of utmost importance. Clean and sterilized utensils should be used. Previous day’s milk or milk kept beyond 24 h should never be given to the baby. Sugar should not be given to infants from birth to 3 months of age, but as the infant grows, quarter to half a spoon of sugar can be added. Milk should be supplemented with vitamins, and sometimes coconut oil or medium chain triglycerides for increasing the nutrient content and calories.

Triggers of adopting cow’s/buffalo’s milk by mothers: Among mothers, the triggers of initiating cow’s or buffalo’s milk are varied. These misconceptions mainly relate to mother’s milk. The factors range from insufficient lactation to making the infant habitual to drinking milk in future. The triggers for adopting cow’s or buffalo’s milk by mothers include: • Perception of no milk for first 24 h after delivery or insufficient lactation. • After long labor, mother is perceived to be too tired to feed baby for some time. • Bovine milk considered to be nutritious for the child offering him/her benefits of proteins, vitamins, and calcium. Because of its nutritional benefits, bovine

Quantity of milk boiled/heated (N = 1589) Average quantity of milk boiled/heated 0.79 L Time for boiling/heating (N = 1589) Average time for boiling/heating 11.38 Min Gas knob while boiling/heating (N = 1589) Gas knob was kept at high flame 7.75% Gas knob was kept at moderate flame 61.68% Gas knob was kept at lowest flame 30.50% Cooling down process (N = 1226) Left it to cool down in a room/kitchen to temperature 45.43% suitable for infants Left it under fan to cool down to the temperature 28.15% suitable to infants Kept the hot milk in a utensil which was kept in cold 12.59% water Tumbled in two utensils to arrive at temperature suitable 12.67% for infants Milk treatment before giving to infants (N = 1589) Cooled the boiled milk and used it 34.60% Re-boiled it, cooled it and used it 23.58% Heated it and used it 21.86% Heated it, cooled and used it 19.95%

Table 5: Feeding practices: modification before feeding Added supplements N = 1618 Yes (%) 81.21 Type of supplements added N = 1314 Sugar (%) 85.24 Water (%) 13.77 Biscuits (%) 4.26 Fennel seeds (%) 3.65 Cardamom (%) 3.42 Infant Cereals (%) 2.66 Time of sugar addition N = 1120 Before milk treatment (%) 8.12 During milk treatment (%) 14.70 After milk treatment (%) 12.08 Just before feeding milk to infant (%) 65.10 Amount of sugar added during feed preparation N = 1120 Average quantity of sugar added (no. of teaspoons) 1.17 Quantity of water added during feed preparation N = 181 Average quantity of water added (in mL) 66.07 Time of water addition N = 181 Before milk treatment (%) 30.73 During milk treatment (%) 36.75 After milk treatment (%) 7.23 Just before feeding milk to infant (%) 25.30

N = Number of respondents.

N, Number of respondents; SEC socioeconomic class.

Table 4: Processing of milk: purchase to consumption

79



80

•

• •

milk has been passed on as the next best substitute for mother’s milk from generations, reinforced by family members like mothers or mother-in-laws To make the child habitual to drinking milk in future, hence most mothers start making the child accustomed from beginning itself. Use of milk as a base for other foods or complementary foods. Easy availability, convenience, and cost factor.

Barriers of adopting cow’s/buffalo’s milk by mothers: Various concerns were also observed among mothers with respect to the usage of cow’s or buffalo’s milk. Some mothers believe that cow’s milk, though thin in consistency (when compared to buffalo’s milk), is not easily digested by infants and hence do not approve giving it to their infants. Hygiene is the one of the most important concern associated with cow’s or buffalo’s milk. Prevailing factors include unclean, unhygienic surroundings of cattle, quality of feed given to the cattle, health of the animal, utensils used for storing milk, leaving milk uncovered in open areas, fear of risk of infestation that would instill infections or any disease to the infants. Also, the adulteration with chemicals or powdered milk in both loose as well as packaged milk is a huge concern. The quality of water used for dilution is another big concern for the mothers.

Discussion While breastfeeding is recognized to be the best, many children are still fed on cow’s or buffalo’s milk during infancy. One of the important observations of this study is that across SECs and zones, mothers start feeding cow’s or buffalo’s milk to their children relatively early in infancy. However, bovine milk contains the nutrients needed for growth and development of the calf, and is a source of lipids, proteins, amino acids, vitamins, and minerals.6 Concern is often shown for use of cow’s or buffalo’s milk to very young children.7 In this study, the HCPs also do not advise cow’s or buffalo’s milk feeding to children below 1 year of age until no other option is available. Most mothers are unaware of the complications of introduction of cow’s or buffalo’s milk in infancy. cow’s or buffalo’s milk has an unbalanced nutrient composition making it unfit for baby’s consumption till 1 year of age. Many studies have reported that consumption of cow’s milk at an early age does not have much benefits and may lead to iron deficiency as it is a poor source of iron.7-11 The cow’s milk is high in protein and sodium

whereas baby requires less. It contains urea which is not good for infant’s health. Also, the trace elements and anti-bodies are absent in cow’s or buffalo’s milk.7 Inappropriate processing and contamination from an unhygienic environment contribute to the development of food-borne pathogens in milk which may adversely affect the health of the infants.12-15 Various epidemiological studies have shown that cattle probably become infected through consumption of water and feedstuffs contaminated with feces and other cattle secretions/ excretions. These food-borne pathogens can even gain into processing plants and persist in bio-films which can lead to postpasteurization contamination.12 Other unhygienic practices such as boiling the milk in uncovered containers (70%) or storage of milk outside refrigerator might also have implications in the overall quality of the milk fed to the infants. In this study, a lot of variation in the storage practices and modification behavior was also observed. For example, dilution of cow’s and buffalo’s milk before boiling is a common practice which may have health implications as the amount of dilution determines the nutrient content of the milk consumed. Over dilution makes milk too watery and in turn compromises the nutrition profile of the milk. On the other hand, insufficient water dilution may lead to indigestion. Microbial contamination of the milk may also occur depending on the unhygienic household practices and the quality of water used for dilution. Additionally, re-boiling of the milk is an uncommon practice among mothers before feeding the infants. The prevalent practices of modification of milk with the use of supplements such as sugar, fennel seeds, cardamom, etc. might also affect the nutritional/microbial profile of milk. However, the exact evaluation of the same is currently unavailable. The Infant and Young Child Feeding (IYCF) guidelines states that breastfeeding should be initiated early and exclusive breastfeeding should be continued for the first 6 months of life. It is also mentioned that the most appropriate feeding strategy for infants and young children is that breastfeeding should be continued for up to 2 years and beyond with adequate complementary foods.16 However, in this study it was observed that doctor’s advice consumption of cow’s or buffalo’s milk by infants if there is no other option available including advice on processing and hygiene. Despite doctors actively advocating best practices to be followed in



cow’s or buffalo’s milk usage, in reality these are not completely adhered to by most mothers. Mothers start giving top feed or complementary foods at their own convenience or as per elders’ advice rather than a doctor’s recommendation. Breastfeeding is ignored in most of the cases once top feed is started. The cleaning practices and usage of utensils is far from satisfactory as only 44% of the mothers boil the feeder bottles. Sterilization of utensils used to prepare baby feed or of the feeding bottle is not always practiced due to various reasons and is mostly done superficially. Mothers continue to give diluted cow’s or buffalo’s milk to their babies and dilution is performed as per situation or personal requirement.

Conclusion

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5. 6. 7. 8.

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Cite this article as: Mayuri M, Garg V, Mukherji C, Aggarwal D, Ganguly S. Bovine milk usage and feeding practices for infants in India. Indian J Public Health 2012;56:75-81. Source of Support: Nestlé India Ltd. Conflict of Interest: The authors of this study are employees of Nestle India Ltd. There are no other conflicts of interest.
