Growth Profile of 100 Breastfeeding Children with Early Introduction of Infant Formulas in Abidjan, Côte d’Ivoire

Objective: To describe the growth profile of breastfeeding babies following early introduction of infant formulas to improve the feeding pattern of the young infant. Methodology: This is a longitudinal descriptive study conducted in 2 medical clinics in Abidjan from 11-Jun-2013 to 15-Dec-2016 on 100 healthy newborn babies with the introduction of infant formulas before 6 months of life. The anthropometrics parameters were compared to those of WHO. Results: The exclusive breastfeeding rate was 5%. Ablactation occurred within 12 months in 95% of cases. All Infants have doubled and tripled their birth weight at 3 and 9 months respectively. The height and the head circumference at birth increased by 50% and 37% respectively at 12 months. Compared to WHO growth charts, the weight gain for the girls at 3 months was 12.4% higher and for the boys was 7.3% higher at 6 months. On the other hands, the statural gain at 12 months was 50% lower than the WHO standards while the head circumference was 37.8% and 45.5% higher than the WHO standards in boys and girls respectively. At 3 months, the prevalence of stunting was 26.1% for boys and 13.3% for girls. Lastly, at 12 months, the BMI showed 10% overweight and 19% obesity. Conclusion: Breastfeeding associated with an early introduction of infant formulas increases the risk of malnutrition of the young infant. We advise to avoid it and recommend an exclusive breastfeeding.


Introduction
During the first 1000 days of life, uncontrolled feeding of the newborn increases the child's risk of malnutrition which will later enhance the possibility of metabolic diseases such as obesity, diabetes and high blood pressure in adulthood [1].
Thus, WHO recommends exclusive breastfeeding for up to 6 months, food diversification from 6 months, family meal in addition to the breastfeeding between 12 -24 months, and final weaning at 24 months [2].
These recommendations have been adopted by the Republic of Côte d'Ivoire since the year 2000 and it is promoted via the National Nutrition Program. This program regularly refreshes the knowledge of health care providers and raises public awareness of the recommendations for a better nutrition of young infants to reduce the current malnutrition rate of 28% for chronic malnutrition, of which almost half (12%) are in the form of severe acute malnutrition [3]. But in practice, we find that in urban areas, many pediatricians deviate from the recommendations and combine to the breast milk a substitute of maternal milk before 6 months. Are the growth patterns of these children comparable to the WHO reference population?
In other words, do these children have a greater risk of malnutrition? The objective of the study was to describe the growth profile of these children as compared to WHO growth standards to improve the feeding behavior of these infants.

Patients
This is a longitudinal descriptive study that took place in two private medical clinics in the city of Abidjan. It covers the period from 11 June 2013 to 15 December 2016.
These two dates correspond respectively to the date of birth of the study first newborn and to the study 100 th newborn 12 months in the study. The choice of the two clinics was made due to preventive consultation provided by pediatricians and trained health personnel in quality requirements and willing to undergo a quality control test.
The study population is made up of newborn; outpatients in these two medical clinics were included in the study, all eutrophic, healthy newborns at term with breastfeeding and breast milk, with the introduction of infant formulas before 6 months of life. They have been monitored monthly over a period of at least 12 months, taking into account the following indicators: weight, height and head circumference. Not included in the study: 1) All eutrophic, malformed newborns at term with a digestive organic pathology. 2) All eutrophic, newborns at term hospitalized in the neonatal period.
3) All eutrophic, healthy newborns at term that the parent did not consent to take part in the study.

Methods
The children included in the study benefited from a monthly preventive consultation with assessment of diet, growth and psychomotor development. The feeding of the infant was conducted by the parents in accordance with the advice provided by the pediatrician.
The appreciation of quantitative growth was done outside the meal, at rest on a calm and non-agitated child. The measures were first taken by the caregiver then checked by the pediatrician. When there was a discrepancy between the two measures, the pediatrician performed a third measure.
The measuring equipment used in both medical centers was identical and ca- The tape measure used was flexible and non-stretchable. The head circumference was measured to the nearest 0.1 cm. Body mass index (BMI) was determined by the following formula: weight (kg)/height 2 (m 2 ). Stunting was defined as a BMI less than the 3 rd percentile, overweight by a BMI greater than 97 th percentile, and obesity by a BMI greater than 99.9 th percentile (Table 1) [4].
At the end of the consultation, the information collected by the pediatrician

1) Total population
Fifty-five girls and forty-five boys were included in the study. The breastmilk substitute was introduced before 3 months in 95% of cases.
At 3 months, all mothers had introduced the breastmilk substitute. The reasons for the introduction of the breastmilk substitute were to resume work (65%), breast milk deficiency (24%) and aesthetics (11%).
The exclusive breastfeeding rate was 5% before 3 months. Ablactation occurred before 12 months in 95% of cases. 8% of the mother had a primary level of education, 49% secondary level and 43% tertiary level of education. Furthermore, 53% of them had an activity with a fixed monthly income, 36% variable while 11% had no occupation.
All study infants have doubled and tripled their birth weight at 3 months and 9 months respectively. The length and the head circumference at birth increased by 50% and 37% respectively at 12 months.

2) Growth profile of boys
The quantitative growth profile of the 45 boys from birth to 12 months is shown in Figure 1. Figure 2 illustrates the growth profile of the 45 boys compared to the WHO reference standards.

3) Growth profile of girls
The quantitative growth profile of the 55 girls from birth to 12 months is shown in Figure 3. Figure 4 illustrates the growth profile of the 55 girls compared to the WHO reference standards.

Discussion
These results should be considered with care because the sample size is small and the children included come only from private medical facilities. The data on the feeding of these children come from the parents' declaration and notified in the consultation register or in the mother and child health booklet by the consultant pediatricians.
A memory bias or transcription error of the data cannot be ruled out. Despite the limitations of the study, the following discussion points emerged. The objective of this work is to describe the growth profile of 100 breast-fed infants with an introduction of an infant formula before the age of six months and followed in preventive consultation for 12 months in two private medical clinics in Abidjan. The study found that the rate of exclusive breastfeeding was very low, 5% of cases.
Before the age of three months, the growth profile of the children, regardless     Regarding the prevalence of exclusive breastfeeding, the study revealed 5%.
This rate is very low compared to the national average of 12% [3].
The main reason given for the early introduction of the breastmilk substitutes at 3 months is the return to work (65%). Indeed, the study reveals that 53% of nursing mothers carry out a fixed-wage activity (employed). The legal duration of maternity leave in Côte d'Ivoire is fourteen consecutive weeks, with eight weeks (2 months) later for delivery [5]. The return to work should not constitute an obstacle to the conduct of breastfeeding since the breastfeeding woman can extract her milk (breast pump) and give it to the infant during the hours of absence. But the extraction of breast milk is challenged by some breastfeeding women for aesthetic reasons, 11% of the cases in the study, because it would favor the flattening of the breasts.
At the work place, about a quarter of the mothers introducing the breast milk substitute early evoke breast milk deficiency as a reason. Hypo-galactorrhea of congenital origin is rare to see and is exceptional cases [6].
In most cases, it is caused by a poor positioning of the child to the breasts [7] [8].
Other reasons have been mentioned by Moyen et al. [9] in Brazzaville to explain the decline of exclusive breastfeeding. According to these authors it is the ignorance and pejorative ideas of mothers educated about breastfeeding.
Mothers with a higher level of education tend to adopt modern psychosocial and societal ideas which lead them to abandon breastfeeding as an ancient nutritional practice [9].
In developed countries, mothers with a higher level of education were more supportive of breastfeeding [10]. Sensitization of breastfeeding women targeting the three reasons mentioned could increase the rate of exclusive breastfeeding reported in the study.
Before 3 months, the growth profile of the children, whatever the sex is harmonious and almost superimposable to that of the WHO standards. This is because the two populations of children are fed mainly with breast milk. But at 6 months the weight and height of the children of the study become lower than the normal while the head circumference remained within the limits of the normal.
In the first six months of life, the population of children responsible for WHO growth standards was exclusively breastfed [11], while the children in the study received in addition substitutes of breast milk. Breast milk contains all macronutrients, micronutrients, water, antibodies, and specific growth factors in sufficient quality and quantity that guarantee the harmonious growth of young infants  [12].
When the nutrition is inadequate during the first 6 months of life, the brain growth is preserved and maintained at the expense of the weight and height. Asse and collaborators [13] reported in 2014 a similar result in France. Between 6 and 12 months, the growth profile of the study children becomes very different. They are bigger at the 97 th percentile but smaller at the 3 rd percentile.
The BMI at 12 month, shows 11.11% overweight, 15.55% obese, 11.1% stunted growth in the boys and 9.1% overweight, 21.8% obese and 3.6% stunted growth in girls. The children fed with infant milk with high protein contents have a significantly body weight and body mass index than those who are breastfed [14].
Oddy W.H. et al. reported that the use of infant formulas other than breast milk before the 6 th month is a risk factor for overweight or obesity [15]. Some infant formulas associated with breasts in our study might have a high protein contents. The high protein content induces the production of insulin-forming amino acids.
This promotes the secretion of insulin-like Growth Factor (IGF1), a growth factor that causes overweight and obesity [16]. In essence, this confirms once again that exclusive breastfeeding should be the mode of nutrition to be favored during the first 6 months of life. Early introduction of infant formulas in addition to breast prior to 6 months promotes immediate malnutrition in young infants and increases the risk of metabolic syndrome in adulthood [1].

Conclusions
The growth profile of breastfed infants with early introduction of infant formulas before six months compared to that of WHO standards shows a tendency towards overweight and obesity. This mode of nutrition should be avoided by pediatricians providing preventive consultations.
We recommend exclusive breastfeeding for up to 6 months in accordance with the guidelines of the National Nutrition Program in Côte d'Ivoire, given the beneficial effects of breastfeeding in the short and long term.