CHAPTER ONE1.0 INTRODUCTION1. 1 BACKGROUNDHealth issues have been one of the primary and indeed a paramount concern in mans quest for knowledge since time immemorial. Good health is basic to our survival. Adequate food and sound nutrition are essential to good health; they are crucial not only for human survival, but also for prevention of and recovery from illness (Ghana Demographic and Health Survey, GDHS, 2003). This is especially so for newborns. A total of 19 million newborns are born every year in the developing world with low birth weight, which is related to maternal malnutrition. Worldwide, more than 9 million children under 5 years of age die each year. Malnutrition underlies a majority of these under 5 deaths, 70% of which occur in the first year of life. Infant and young child feeding practices directly impact the nutritional status and, ultimately, the child survival of children under 2 years of age. Therefore, improving infant and young child feeding is critical to ensuring their optimal health, nutrition and development (Unicef.org, 2008). Appropriate feeding practices are of fundamental importance for the survival, growth, development, health and nutrition of infants and children. Feeding practices are one of the underlying determinants of childs nutritional status which in turn influence the risk of illness and ultimately death (GDHS,2003). Breastfeeding, according to the Oxford Advanced Learners Dictionary, means giving the baby breast milk soon after birth. The baby is put to breast and begins to suck the mothers nipple to stimulate the breast to release milk. Also en.wikipedia.org defines breastfeeding as the feeding of an infant or young child with breast milk directly from female human breast ( i.e. via lactation) rather than from a baby bottle or other containers.Breastfeeding is sufficient and beneficial for an infants nutrition in the first six months of life. Exclusive breastfeeding implies feeding the infant only with breast milk without any additional food or drink, not even water (WHO, 2003). According to UNICEF.org.media (2008), high average with optimal breastfeeding practices, especially exclusive breastfeeding for the first six months of life, could have the single largest impact on child survival, with the potential to prevent 1.4 million under five deaths. Yet in 2008 rates of exclusive breastfeeding were only about 37% in developing countries. The World Health Assembly (WHA), in May 2001, recommended exclusive breastfeeding for the first six months of a childs life. It emphasized the media role in promoting and protecting exclusive breastfeeding to improve child health. Since Ghana adopted this policy (Exclusive breastfeeding for the first six months), various seminars and programs are being held and information being spread through National and Private Television stations, radios and news papers to promote and encourage the practice. All women are encouraged to breastfeed their infants exclusively for the first six months and then complement the breastfeeding with nutritious food for at least two years. Pre-lacteal feeding (given something other than breast milk in the first three days of life) is generally discouraged since it inhibits breastfeeding and expose the new born infant to illness (GDHS,2003). Despite the recommendation by the WHA, some infants are fed with complementary foods in addition to breast milk. There are other infants, especially those in orphanage homes in Ghana, who do not receive any breast milk. One way of measuring a healthy baby is to look at the weight gain. If the baby gains enough weight during its first year then everything is fine. This study is intended to compare the growth of babies under four forms of feeding practices namely exclusive breastfeeding, breastfeeding with water, breastfeeding with complimentary foods and feeding without breast milk. This would be done by comparing their weights for the first nine months of their life.Children gain weight and grow more rapidly during infancy and childhood than at any other time in life. However, some children fail to gain weight at a normal rate, either because of expected variations related to genes, being born prematurely, or because of under nutrition, which may occur for a variety of reasons (Rebecca, T. K., 2006). Under nutrition is sometimes called a growth deficit or failure to thrive. It is important to recognize and treat children who are not gaining weight normally, because it may be a sign of under nutrition or an underlying medical problem that requires treatment. This, according to Rebecca, T. K. (2006), is because, each year, under nutrition contributes to the deaths of about 5.6 million children younger than 5 years in the developing world. Another 146 million children within this age group are underweight and are at an increased risk of early deaths, illness, disability and underachievement. In least developed countries, 42 percent of children are stunted and 36 percent are underweight. Under nutrition can have complications such as a weakened immune system, shorter than normal height, or difficulties with learning apart from deaths in children. These complications are more common in children who are undernourished for a long period of time (Rebecca, T. K., 2006).Poor weight gain is defined as gaining weight at a slower rate than other children who are the same age and sex. "Normal" ranges for weight and height are based upon the weight and height of thousands of children. In the United States, standard growth charts are published by the Centers for Disease Control and Prevention; these charts are available for boys and girls and are appropriate for all races and nationalities. Weight gain normally follows a predictable course from infancy through adolescence. However, some children do not gain weight normally from birth, while other children gain weight normally for a while, then slow or stop gaining weight. Weight gain usually slows down before the child slows or stops growing in length. A child is said to have poor weight gain if he or she does not grow at the expected rate for their age and sex. Poor weight gain is not a disease, but rather a symptom, which has many possible causes (Rebecca, T. K., 2006). Three factors account for poor weight gain in children. The first factor includes not consuming adequate amount of calories or the right combination of protein, fat, and carbohydrates. The second factor is when the child is not absorbing adequate amount of nutrients, which leads to poor weight gain. The third factor has to do with requiring a higher than normal amount of calories (Rebecca, T. K., 2006). Poor weight gain can occur as a result of a medical problem, a developmental or behavioral problem, and lack of adequate food, a social problem at home, or most frequently, a combination of these problems (Rebecca, T. K., 2006). If an infant or a child slows or stops gaining weight, it is important to try to determine and treat the underlying cause. The first step is a complete medical history and physical examination. Most children will not require blood testing or imaging tests, although testing may be recommended in certain situations. Parents should also mention if they have eliminated foods from the child's diet due to concern about the effects of these foods (e.g. abdominal pain, diarrhea, "hyperactivity"). The provider may also ask about the child's household, including who lives in the child's house, if there have been recent changes or stresses (e.g. divorce, illness, death, new sibling), or if anyone in the house has a medical or psychiatric illness. The provider may also ask about the food supply (e.g. if there have been days when anyone in the family went hungry because there was not enough money for food). Although these questions can be difficult to answer, it is important to be honest (Rebecca, T. K., 2006).1.1.1 Growth Monitoring In Infants and ChildrenFor a relatively small expenditure per child, growth monitoring can greatly strengthen preventive health programmes. Growth is the best general index of the health of an individual child, and regular measurements of growth permit the early detection of malnutrition, frequently association with diarrhea, and other illnesses, when remedial action is relatively easy. Although acute signs of malnutrition are easily noted by health workers, it is often too late, and always more expensive, to help the severely malnourished children (UNICEF, 2006).For early detection of children with growth retardation and high risk of malnutrition and mortality, health workers need special tools and training in growth monitoring. The growth status of children is a measure of the health and well-being of the whole community. Birth weight is of a particular significance in determining the nutritional status of a community, as low birth weight is a good indicator of subsequent illness and death in children (UNICEF, 2006). Various body measurements are used to access growth. Some are easier to use, more accurate and more useful than others. Monitoring the growth of a child usually requires taking the same measurements at regular intervals and seeing how they change. A single measurement only indicates the childs size or weight is increasing, staying the same, or declining. Careful repeated measurements and comparisons with previous measurements are necessary because most children will continue to grow a little, unless they are very ill, and it is easy to mistake some growth for adequate growth. Growth measures are usually compared to a reference population. Gathering data to establish a local reference population is a major undertaking. Therefore, western standards are usually used for comparison, such as Tanner and Boston, or more recently, those of the National Centre for Health Statistics (UNICEF, 2006).1.1.2 Weight-For-Age of ChildrenTo obtain weight-for-age, the weight of the child (in kilograms) is compared with that of an ideally healthy child of the same age from a reference population. This is the basis of the weight-for-age, or Gomez classification of nutritional status. A child weighing less than 60 per cent of the reference weight-for-age is considered to be severely malnourished. For these reasons, countries have different ways of assessing the growth of children through weight taking and at different places. For instant, in Indonesia 2.5 million infants and young children are being weighed regularly at the traditional monthly meetings of village women. The results are entered on growth charts kept by the mothers themselves. In Thailand, a programme based on the home use of growth charts by parents in several villages, helped to eliminate completely third degree malnutrition, and reduced second degree malnutrition by 44 per cent during 1981 1982, even though no additional food was provided. In Colombia, improvements in weight gain for a majority of children suffering from mild, moderate and severe malnutrition have been achieved in poor communities by nutrition programmes incorporating the Carnet de Salud or health card kept at home by mothers. In Jamaica, a systematic programme to improve the health and growth of over 6,000 young children using growth charts, immunization and nutrition education and milk supplements, has resulted in a 40% decline in the prevalence of malnutrition and a 60 percent fall in infant mortality (UNICEF, 1985). In Ghana, mothers and family members have traditionally used variety of indicators and milestones when assessing their childrens growth. The signs used and local standards children are compared to vary culturally, but are important factors affecting child care practice. These were taken into consideration and used by the community health workers to understand the communitys perceptions, so that they could be related to the use of growth charts.One quite productive community survey in central Ghana did examine closely the growth related beliefs and practices of local mothers and families in order to suggest ways of applying the information to improve rate monitoring at the local level (Love et al 1985). One key question concerned how mothers know when their children are growing or not growing well. The responses were rich and comprehensive in scope, covering indicators such as appetite, stages of physical and mental development, general health appearance and the feel and look of the skin. Height and weight were also mentioned, as well as variation in mood and activity level (Brownlee, 1990). A wide range of physical changes both for periods of good and poor growth were mentioned. Children growing well cry and move normally. When growth is poor the abdomen becomes distended, bigger than normal, the hair turns brown or grayish, the face puffy or pale, the fontanel sunken or large. Observations were both sensitive and detailed, and often included accurate descriptions of the signs of anemia and dehydration, two major causes of child mortality in Ghana. Size was emphasized, with clothing often mentioned as a useful indicator: in poor growth, dresses become loose around the body and clothes bought for a young child are still a good fit many months later (Brownlee, 1990).Traditionally anthropometric measures were some of the most interesting. It is customary in central Ghana, as in many other cultures, to make strings or beads for a newborn and put them around the waist, wrist and legs. They are intended as decoration but used by many parents to assess growth. One mother explained that by the time the child had reached the age of 5 months, the bead-strings around the waist should have been changed or adjusted five times. Other items mentioned included metal bracelets, necklaces and finger rings (Brownlee, 1990). 1.1.3 Interventions to Improve Weight Gain of Infants and ChildrenIn 2000, the Center for Diseases Control and prevention (CDC) established the International Micronutrient Malnutrition Prevention and Control Program (IMMPaCt) to support the global effort to eliminate vitamin and mineral deficiencies, or hidden hunger in both developed and developing nations. Through the IMMPaCt program, CDC provides funding and/or technical assistance directly to countries through cooperative and interagency agreements with UNICEF, the World Health Organization (WHO), the U.S. Agency of International Development (USAID), and the Global Alliance for Improved Nutrition (GAIN), and the Micronutrient Initiative (MI). With these partners, CDC has assisted countries in assessing the burden of hidden hunger through national surveys and surveillance systems that allow countries to monitor the coverage and impact of their food fortification and micronutrient supplementation programs. In addition, computer and web-based training tools and regional and national training workshops developed by CDC have strengthened the capacity of countries to assess the burden of poor weight gain through malnutrition, track the effectiveness of interventions strategies through surveillance systems, and plan social marketing and health communication strategies to promote the consumption of vitamin- and mineral-fortified foods.In 2002, in collaboration with the WHOs Eastern Mediterranean Regional Office (EMRO), CDC provided funding support and consultation toward a national micronutrient survey to generate baseline data on iron status of adult women and preschool children in order to monitor the impact of the recently initiated national flour fortification program in Jordan. To help improve nutrition worldwide, the CDC IMMPaCt Program helped launch the Flour Fortification Initiative (FFI) in 2002. The Initiative was formalized in 2005. The FFI Leaders Group, a network of government and international agencies, wheat and flour industries, academia, and consumer and civic organizations, was established to promote flour fortification. FFI supports fortification of flour with essential vitamins and minerals, especially folic acid and iron, as one important way to help improve the nutritional status of populations, especially women and children, around the world.In many Asian and African countries commercially produced infant foods are either not commonly used or readily accessible through markets in remote areas. Through the IMMPaCt program, CDC is actively planning pilot interventions in Kenya and Tajikistan to assess the feasibility of alternative approaches to sustainable distribution, through small local markets and house-to-house sales, of easy-to-use, in-home fortificants to enrich baby foods. These efforts will require public-private-civic sector partnerships to be nurtured and strengthened over time.

1.2 STATEMENT OF THE PROBLEM Weight gain is one of the observable signs of growth especially at the early stages of life. Regular assessment of weight gain among babies has been a way of assessing their health status and growth. Too much of it leads to child obesity while too little is a sign of ill-health. Ghana is much concerned about the health and growth of her children and consequently instituted a monitoring mechanism for babies (both prenatal and postnatal) up to the age of sixty months. This mechanism involves monthly assessment of weight right after birth and compulsory immunization against some diseases (six childhood killer diseases) such as Tuberculosis, Poliomyelitis, Diphtheria, Yellow fever etc at every public or private health center. One could access these weight records when a visit is made to these centers.Weight change, especially among individual children, could be biological (variation related to genes), due to socio-economic status of the mother or due to childs nutritional status. Children who show poor weight gain could be a sign of malnutrition. Appropriate feeding practices are of fundamental importance for the growth, survival, development, health and nutrition of infants and children (GDHS, 2003). Parents do not see the need to practice a particular feeding type and feel reluctant to participate in the monthly weighing exercise as they do not know the importance of them. It is in the light of this that the study seeks to examine the relationship between infant feeding practice and weight gain to enable the parents appreciate the feeding practice that is beneficial and results in good health of their babies. 1.3 THE OBJECTIVE(S) OF THE STUDYThe main objective is to find out if different forms of feeding practice have effect on weights of babies (growth of babies). To do this the study seeks to:i. Compare the weights of babies under four different forms of feeding practice namely, Exclusive breastfeeding, breastfeeding with water only, breastfeeding with any other food (water inclusive) and feeding without breast milk (non-breastfeeding) . ii. Investigate how weights vary by months for the four modes of feeding practices.iii. Determine which mode(s) of feeding practice differ(s) from others.iv. Find out what happens to the weights for the first three months after introduction of complimentary (other) foods in case of exclusive breastfeeding.v. To compare the rate of weight gain for the age periods 1-3 months, 4-6 months and 7-9 months. 1.3.1 HypothesesIn order to achieve the set objective, the following hypotheses are outlined1. H: There is no difference in weight gains under the different feeding practices. (H: = = = ) H ; There is at least one feeding practice that differ in weight gain from the rest. (H: = for i and j )2. H: Feeding practices have no effect on weight of babies H: Feeding practices affect weight of babies 1.4 RESEARCH QUESTIONSSome concerns which this study is attempting to address are (a) Is the monthly increase in weight influenced by the birth weight of a baby?(b) Does the type of feeding practice influence the weight of a baby?(c) Which age period do we have high rate of weight gain? 1.5 SIGNIFICANCE OF THE STUDYA baby must have proper nutrition to grow and thrive. According to Ghana Health Service (GHS) (2003), the most cost effective way to address the pressing public health challenge of malnutrition is to prevent it. That means ensuring that all of the children who are normal weight at birth continue within the normal range, and those who are low birth weight at birth are brought swiftly into a healthy growth range. If the baby weighs too little, it is important to ensure that the nutrition it needs to grow is given. When the babys weight is too much, and the baby is overweight or obese, one may need to consult a doctor for a more balanced and healthy diet.Many researchers including Ghanaian researchers have shown that food insecurity is not the most important factor that contributes to a high prevalence of under nutrition. Instead inappropriate feeding and caring practices of children and mothers, poor environment (e.g. poor sanitation and hygiene), and limited utilization of basic health care services are among the most important determining factors (GHS, 2003). From economic point of view, poor weight gain causes ill-health of babies which is a potential source of drain of parents income. Appropriate feeding method ensures the optimum weight gain for a baby. The research is to encourage parents, especially lactating mothers, to practice appropriate feeding method for their babies. This will help reduce instance of diseases associated with improper feeding practices and ultimately help reduce infant mortality.1.6 SCOPE OF THE STUDYThe study was carried out at three centers in Mampong in the Ashanti Region of Ghana. The centers were Mampong Babies Home, Mampong Technical College of Education Primary School New Darman, and Akyeremade - near Birth and Death Registry. Basically, the data involving feeding without breast milk was collected from the Babies Home while the data on the other three feeding practices were obtained from the two centers mentioned. The respondents in the research were babies of not less than nine months as the data involves the birth weight and weights for the first nine months after birth.1.7 THE OUTLINE OF THE STUDYThe study is divided into five chapters. Chapter one is the Introduction and it focuses on the background of the study, the statement of the problem, the objectives of the study, the research questions, the significant of the study, the scope of the study and the outline of the study. Chapter two presents the review of literature related and relevant to the study. Chapter three deals with the Methodology which involves the sampling procedure, data sources and collection, and the overview of the analysis and modeling techniques. It also entails the underlying basic theories and concepts and how they are applied. Chapter four presents the Data analysis and the results of the analysis. The last chapter, Chapter five, discusses the key findings of the study which are followed by conclusions and recommendations.

CHAPTER TWO2.0 LITERATURE REVIEWParents are primarily responsible for their babys health. It is extremely important for them to understand the unique nutritional requirement and feeding practices of infants. A lot of studies have been carried out concerning nutritional requirements and feeding practices of infants.2.1 FEEDING PRACTICES OF INFANTSThe two main ways of feeding infants, which are orthodox, are Breastfeeding and Non-breastfeeding. Breastfeeding has been the basic norm for humans from the genesis of creation while Non-Breastfeeding is artificial to human race. Non-Breastfeeding takes place in most cases when Breastfeeding is medically contraindicated such as health of mother, the baby being unable to breastfeed, absence of mother, personal preferences, beliefs and experiences.Breastfeeding is practiced in three main ways. It can be done exclusively or with water only or with water and other foods. The third form, breastfeeding with water and other foods may be due to a baby being considered at risk for malnutrition, lactation insufficiency, decision or preference of parents etc. Both Non-Breastfeeding and breastfeeding with water and other foods are considered automatic, for example Bottle-feeding, and have the benefit of allowing freedom to leave the baby with others (Wambach and Koehn, 2004). 2.1.1 BreastfeedingBreastfeeding was the rule in ancient times up to recent human history and babies were carried with the mothers and fed as required. With 18th and 19th century industrialization in the Western world, mothers in many urban centers began dispensing with breastfeeding due to work requirement in urban Europe. Breastfeeding declined significantly from 1900 to 1960, due to improved sanitation, nutritional technologies, and increasingly negative social attitude towards the practice (Riordan, 1980). By the 1960s the predominant attitude to breastfeeding was that it was something practiced by the uneducated and those lacking temperament of lower classes. The practice was considered old fashioned and a little disgusting, left for those who could not afford infant formula and discouraged by medical practitioners and media of times. In fact, letters and editorials to the womens magazine Chatelaine from 1945 to as late as 1995, regarded breastfeeding with a predominately negative attitude. However, since the middle 1960s there has been a steady resurgence in the practice of breastfeeding in Canada and the US, especially among more educated affluent women (Nathoo, 2009).After the addition of solid food, mothers are advised to continue breastfeeding for at least a year. The World Health Organisation recommends nursing for at least two years or more. The World Health Organisation (WHO) and the American Academy of Pediatrics (AAP) emphasize the value of breastfeeding for mothers as well as children. Both recommend exclusive breastfeeding for the first six months of life. The AAP recommends that this be followed by supplemented breastfeeding for at least one year, while WHO recommends that supplemented breastfeeding continues two years or more. While recognizing the superiority of breastfeeding , regulating authorities also work to minimize the risk of artificial feeding (Nathoo, 2009).According to Ip S, Chung M, Raman G, et al (2007) , scientific research such as the studies summarized in a 2007 review for the US Agency for Healthcare Research and Quality (AHRQ) and a 2007 review for the WHO (Horta BL, 2007) have found numerous benefits of breastfeeding for the infant. According to AAP, research shows that breastfeeding provides advantages with regard to general health, growth and development. Not breastfeeding significantly increases risks for a large number of acute and chronic diseases including lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infections, and necrotizing enterocolitis (Lucas, A; Cole, T.J, 1990). There are a number of studies that show a possible protective effect of breast milk feeding against sudden infant death syndrome, insulin dependent diabetes mellitus, Crohns disease, ulcerative colitis, lymphoma, allergic diseases, digestive diseases and a possible enhancement of cognitive development (PEDIATRICS, Feb., 2005).Under modern health care, human breast milk is considered the healthiest form of milk for babies (Picciano, M., 2001). Breastfeeding promotes health for both mother and infant and helps to prevent diseases (Riordan, JM., 1997). Longer breastfeeding has also been associated with better mental health through childhood and into adolescence (Ody, Wendy H.; Kendall GE.; et al, 2010). Exclusive breastfeeding for the first six months of life has the single largest impact on child survival (Unicef.org. media ,2008). Supplementing breast milk before six months is unnecessary and is strongly discouraged because of the likelihood of contamination, the unaffordability of breast milk substitutes, and the resulting increased risk of diarrheal diseases. The early introduction of liquids and solids reduces milk output because the production and release of milk is influenced by the frequency and intensity of sucking (GDHS, 2003).Despite the recommendations that babies be exclusively breastfed for the first 6 months, less than 40% of infants below this age are exclusively breastfed worldwide. The overwhelming majority of American babies are not exclusively breastfed for this period in 2005 under 12% of babies were breastfed exclusively for the first 6 months, with 60% of babies of 2 months of age being fed formula and approximately one in four breastfed infants having infant formula feeding within two days of birth (WHO, 2008).Despite the high breastfeeding prevalence (97%) in Ghana, the majority of infants are not fed in compliance with WHO / UNICEF recommendations (World Health Assembly, 2001). The recommendations call for a period of exclusive breastfeeding for six months and the introduction of complementary foods after the age of six months. Fifty-three percent (53%) of children under six months of age are exclusively breastfed in Ghana as at 2003, (GDHS, 2003), which is a slight increase over the proportion reported in the 1998 GDHS (Ghana Statistical Service and MI, 1999). Exclusive breastfeeding drops sharply from 65% at age 2 3 months to 39% at age 4 5 months. Further, 6% of children aged 2 3 months and 32% of children aged 4 5 months are receiving complementary foods in addition to breast milk. This indicates that there are many infants who are at risk of being exposed to bacterial contamination and poor quality foods, even if they started out well with early initiation of breastfeeding (GDHS, 2003). 2.1.2 Artificial FeedingArtificial Feeding involves not breastfeeding and supplementing breastfeeding with other foods.Experts agree that breastfeeding is beneficial and have concerns about the effects of artificial formulas. Artificial feeding is associated with more deaths from diarrhea in infants in both developing and developed countries. There are few exceptions, such as when the mother is taking certain drugs or is infected with hum T lymphotropic virus, or has active untreated tuberculosis. In developed countries with access to infant formula and clean drinking water, maternal HIV infection is an absolute contraindication to breastfeeding (regardless of maternal HIV viral load or antiretroviral treatment) due to the s risk for mother to child HIV transmission (Horton, 1996).Infant formula is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle feeding or cup feeding from powder (mixed with water) or liquid (with or without additional water). The US Federal Food, Drug and Cosmetic Act (FFDCA) defines infant formula as a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk (Wells, J.C.K., 1996).A 2001 WHO report found that infant formula prepared in accordance with applicable Codex Alimentarius Standards was a safe complementary food and a suitable breast milk substitute. In 2003, the WHO and UNICEF published their Global Strategy for infant and young child feeding which restated that processed food products for infants and young children should when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission, and also warned that lack of breastfeeding and especially lack of exclusive breastfeeding during the first half year of life are important risk factors for infant and childhood morbidity and mortality. In particular, the use of infant formula in less economically developed countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation conditions, including lack of clean water and lack of sanitizing equipment (WHO, 2003). UNICEF(2007), estimates that a formula fed child living in unhygienic conditions is between 6 and 25 times more likely to die of diarrhea and four times more likely to die of pneumonia than a breastfed child.Throughout history, Schuman (2003) stated, mothers who could not breastfeed their babies either employed a wet nurse or less frequently, prepared food for their babies, a process known as dry nursing. Baby food composition varied according to region and economic status (Oliver, 2004). As early as 1846, scientists and nutritionists noted that an increase in medical problems and infant mortality was associated with dry nursing. Improvement of quality of manufactured baby foods gave birth to Raw milk formulas (mixture of cow milk, water, cream, and sugar or honey in specific ratios) to achieve the nutritional balance believed to approximate human milk reformulated in such a way as to accommodate the believed digestive capability of the infant (Fomon, 2001).In 1920s and 1930s, evaporated milk began to be widely commercially available at low prices, and several clinical studies suggested that babies fed with evaporated milk formula thrive as well as breastfed babies. Then came commercial Formulas followed by Generic brand formulas and later Follow on toddler formulas (Fomon, 2001).The global infant formula market has been estimated at $7.9 billion, with North America and Western Europe accounting for 33% of the market and considered largely saturated, and Asia representing 53% of the market. Infant formula is the largest segment of the baby food market, with the fraction given as between 40% and 70% (Markos, 2005).Leading health organizations (e.g. WHO, US CDC and Department of Health and Human Services) are attempting to reduce the use of infant formula and increase the prevalence of breastfeeding from birth through 12 to 24 months of age through public health awareness campaigns (CDC, 2007). The specific goals and approaches of these breastfeeding promotion programs, and the policy environment surrounding their implementation, vary by country. As a policy basic framework, the International Code of Marketing of Breast-Milk Substitutes, adopted by the WHOs World Health Assembly in 1981, requires infant formula companies to preface their product information with statements that breastfeeding is the best way of feeding babies and that a substitute should only be used after consultation with health professionals. The Baby Friendly Hospital Initiative also restricts use by hospitals of free formula or other infant care aids provided by formula companies (WHO, 1981). 2.2 NUTRITIONAL STATUS AND PREVALENCE OF UNDERWEIGHT CHILDREN IN AFRICAOn nutritional status of children in Ghana, according to the 2003 GDHS, 30% of children under five are stunted and 11% severely stunted. Weight for age results show that 22% of children under five are underweight, with 5% severely underweight.Dinesh et al (2006) studied the nutritional status of under-five children and whether infant feeding practices are associated with the under nutrition in anganwari (AW) areas of urban Allahabad. Under-five-years children and their mothers in selected four anganwari areas of urban Allahabad (UP) participated in the study. Nutritional assessment by WHO criterion (SD- classification) using summary indices of nutritional status: weight-for-age, height-for-age and weight-for-height were done. Normal test of proportions, Chi-square test for testing association of nutritional status with different characteristics and risk analysis using odds ratios with 95% confidence intervals was also done. Among all under five children surveyed, 36.4% underweight ( FSource DF Type111 SS Mean Square F-Value Pr F G-G H-F Sex 7 884.6088 126.3727 522.75 0.0001 0.0001 0.0001Sex*Sex 7 1.9994 0.2856 1.18 0.3108 0.3119 0.3126Error (sex) 749 181.0679 0.2417 The results in table 4.9b present insignificant test for the sex by sex interaction with P value of 0.3108 at 5% level of significance. It is concluded therefore that the effect of interaction of sexes is not significant on weight gain by the children. It must be noted here that since sex is composed of two mutually exclusive sets (male and female), there is no possibility of interaction of sexes to produce any effect.4.3.7 Univariate Analysis of Variance by Feeding PracticeTable 4.10a and 4.10b shows the Repeated Measures ANOVA test of Hypotheses for Between Subjects Effects and for within subject effects respectively.

Table 4.10a Tests of Hypotheses for Between Subjects Effect. (ANOVA for Feeding Practice)Source DF Type 111 SS Mean Square F-value Pr FPractice 3 140.0670 46.6890 5.25 0.0021Error 105 934.5417 8.9004The Between Subjects effects test in table 4.9a produces a P-value of 0.0021. This does not support the hypothesis of equal mean effects. Hence the test for feeding practice is significant indicating that the weight of babies is influenced by the feeding practice. Table 4.10b Univariate Analysis of Variance for within Subject Effects (Univariate Tests of Hypotheses for Within Subjects Effects) Adj. Pr > FSource DF Type111 SS Mean Square F-Value Pr F G-G H-F Practice 7 888.4970 126.9281 555.84 0.0001 0.0001 0.0001 Prac.*Prac. 21 15.2276 0.7251 3.18 0.0001 0.0030 0.0025Error (Prac.) 735 167.8398 0.2284 In the within subject effect test above (Table 4.8b), the interaction of feeding practices is shown to be significant at = 0.05 significance level with P-value of 0.0001.

4.3.8 Repeated Measures Multivariate Analysis of Variance (MANOVA)The factors, feeding practices and sex are considered for multivariate analysis using repeated measures analysis. Tables 4.11 (a, b and c) show the output for extreme measures for the factors. There are seven columns in each of the tables. The effects of the factors are in the first column, the extreme measures for each factor (statistic) in column two, the values of the extreme measures in column three and F values in column four. Numerator degrees of freedom, Denominator degrees of freedom and the P-value are in columns five, six and seven respectively.Table 4.11 Multivariate Repeated Measures Analysis on Weight Gain(a) MANOVA Test Criteria and Exact F Statistics for the Hypothesis of no SEX EffectEffect Statistic Value F Num DF Den DF Pr FSex Wilks Lambda 0.0930 140.74 7 101 0.0001 Pillais Trace 0.9070 140.74 7 101 0.0001 Hotelling-Lawley Trace 9.7545 140.74 7 101 0.0001 Roys Greatest Root 9.7545 140.74 7 101 0.0001

(b) MANOVA Test Criteria and Exact F Statistics for the Hypothesis of no PRACTICES EffectEffect Statistic Value F Num DF Den DF Pr > FPractice Wilks Lambda 0.0880 146.70 7 99 0.0001 Pillais Trace 0.9121 146.70 7 99 0.0001 Hotelling-Lawley Trace 10.3729 146.70 7 99 0.0001 Roys Greatest Root 10.3729 146.70 7 99 0.0001(c) MANOVA Test Criteria and F Approximations for the Hypothesis of no PRACTICES*PRACTICES Effects.Effect Statistic Value F Num DF Den DF Pr > FPrac*Prac Wilks Lambda 0.7320 1.56 21 284.82 0.0591 Pillais Trace 0.2908 1.55 21 303 0.0606 Hotelling-Lawley Trace 0.3355 1.57 21 200.45 0.0607 Roys Greatest Root 0.1983 2.86 7 101 0.0091The results in the tables show that both sex and feeding practice are influential factors in determining the weight gain of children of age 1 9 months. This is as a result of p-value for all the extreme measures being 0.0001 at 5% significance level.

4.4 FURTHER INFERENTIAL ANALYSISTable 4.12 represents covariance structures investigated in selecting an appropriate covariance structure of the random errors.Table 4.12 Covariance Structures InvestigatedCOVARIANCE STRUCTUREAICAICCBIC

COMPOUND SYMMETRY2062.82062.82068.2

UNSTRUCTURED1271.31275.71392.4

FIRST ORDER AUTOREGRESSIVE1407.41401.41406.7

FIRST ORDER ANTE-DEPENDENCE1257.61258.21303.3

HETEROGENEOUS FIRST ORDER AUTOREGRESSIVE1350.01353.21379.7

HETEROGENEOUS COMPOUND SYMMETRY1963.81964.11990.7

HETEROGENEOUS TOEPLITZ1333.71334.31379.4

FIRST ORDER AUTOREGRESSIVE MOVING AVERAGE1394.81394.91402.9

HUYNH-FELDT1974.51974.72001.4

TOEPLITZ1373.51373.71397.7

VARIANCE COMPONENT2876.32876.32879.0

From the table the smallest value is 1257.6 which is in the row of the First Order Ante-Dependence corresponding to the AIC column. Thus the best covariance structure to be used is the Ante-Dependence. 4.4.0 Longitudinal Model with Ante-dependence Covariance Structure (Mixed Procedure)4.4.1 Model Information The Model Information table, Table 4.13, shows the name of the data set, the dependent variable, the covariance structure used in the model, the subject effect, the estimation method to compute the parameters for the covariance structures (the default estimation method is REML), the residual variance method, the fixed effects standard error method and the method to compute the degrees of freedom.Table 4.13 Model information Data Set SASUSER.SEK Dependent Variable WEIGHT Covariance Structure Ante-dependence Subject Effect RESPONDENTS Estimation Method REML Residual Variance Method None Fixed Effects SE Method Model-Based Degrees of Freedom Method Satterthwaite 4.4.2 Dimensions The Dimensions table below, Table 4.14, lists the sizes of the relevant matrices. The table is useful in determining CPU time and memory requirements.

Table 4.14 Dimensions Covariance Parameters 17 Columns in X 9 Columns in Z 0 Subjects 109 Max Obs Per Subject 9 Number of Observations Read 986 Number of Observations Used 981 Number of Observations Not Used 5

4.4.3 Iteration History The Iteration History table (Table 4.15) describes the optimization of the residual log likelihood. The minimization is performed using a ridge-stabilized Newton-Raphson algorithm, and the rows of the table describe the iterations that this algorithm takes in order to minimize the objective function.

Table 4.15 Iteration History Iteration Evaluations -2 Res Log Like Criterion 0 1 2874.32193062 1 2 1238.12934187 0.04301972 2 1 1230.70751929 0.02156881 3 1 1224.01108546 0.00134184 4 1 1223.58269601 0.00009122 5 1 1223.55544908 0.00000076 6 1 1223.55523153 0.00000000 *Convergence criteria met4.4.4 Covariance Parameter Estimates The covariance Parameter Estimates table (Table 4.16 in Appendix C) shows the parameter estimates for the Ante-dependence covariance structure.4.4.5 Fit Statistics The Fit Statistics table provides information to be used to select the most appropriate covariance structure. Akaikes Information Criterion (AIC)(Akaike,1974) penalizes -2 residual log likelihood by twice the number of covariance parameters in the model. The smaller the value, the better the model. The finite-sample version of the AIC (AICC) is also included. The Schwarzs Bayesian Information Criterion (BIC)(Schwarz,1978) also penalizes the -2 residual log likelihood. In The Fit Statistics table below (Table 4.17) AIC is the best option.

Table 4.17 Fit Statistics -2 Res Log Likelihood 1223.6 AIC (smaller is better) 1257.6 AICC (smaller is better) 1258.2 BIC (smaller is better) 1303.3 4.4.6 Null Model Likelihood Ratio Test The Null Model Likelihood Ratio Test shows a test that determines whether it is necessary to model the covariance structure of the data at all. The test statistic is -2 times the log likelihood from the null model (model with an independent covariance structure) minus -2 times the log likelihood from the fitted model. The p-value is used to assess the significance of the model fit. Therefore for the p-value of 0.0001, the model is considered significant at 5% level of significant. This is shown in table 4.18.Table 4.18 Null Model Likelihood Ratio Test DF Chi-Square Pr ChiSq 16 1650.77 0.00014.4.7 Solution for Fixed Effects Table 4.19 contains the solution for Fixed Effects. It contains the estimates, standard errors, the degrees of freedom, the t-value and the p-values for each of the fixed effects listed in column one. From the table, the initial weight (birth weight), monthly weight gains, and the gender are shown to be significant. This is so as the p-value for each of the effects mentioned is 0.0001. Feeding without breast milk has p-value 0.023 which shows that the practice is significant. Exclusive breastfeeding and Breastfeeding with water only are found not to be significant.Table 4.19 Solution for Fixed Effects Effect Gender Practices Estimate Std. Error DF t-value Pr |t|Intercept 1.8824 0.3830 108 4.91 0.0001Birth weight 0.7969 0.1151 108 6.92 0.0001Month 0.4275 0.01241 157 34.43 0.0001Gender Female -0.2450 0.1063 108 -2.31 0.0230Gender Male 0 . . . .Practice BFW -0.03157 0.1483 108 -0.21 0.8318Practice Exclusive -0.09133 0.1449 108 -0.63 0.5298Practice NBF -1.0019 0.1630 108 -6.15 0.0001Practice BWFO 0 . . . .4.4.8 Type 3 Tests of Fixed Effects The Type 3 Test of Fixed Effects table (Table 4.20) shows the hypothesis test for the significance of each of the fixed effects. A p-value is computed from an F distribution with the numerator and denominator degrees of freedom. The p-values are given as 0.0001 for each of the following fixed effects: Birth weight, monthly weight gain and Feeding Practices. The p-value for Gender is 0.0230. Thus these effects are considered significant under this test. Table 4.20 Type 3 Test of Fixed Effects Effect Num DF Den DF F-Value Pr F Birth weight 1 108 47.92 0.0001 Month 1 157 1185.55 0.0001 Gender 1 108 5.32 0.0230 Practices 3 108 16.95 0.0001

CHAPTER FIVE5.0 DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS5.1 DISCUSSIONS OF RESULTS The study used a random sample of 109 babies. The weights of these babies were recorded repeatedly for nine months. The birth weight and the feeding practice of each of the babies were also recorded. The study was intended to find out whether the monthly weight of babies recorded at the weighing centers were significantly different and if birth weight, age, sex and feeding practice could contribute to weight changes.At the exploratory analysis stage it was found out that there was generally an increasing trend of weights for all the babies. The descriptive statistics of the mean monthly weights of the babies suggested that those under exclusive breastfeeding had higher weights than the others for the first six months after birth. The babies under breastfeeding with water only and breastfeeding with water and any other food were second and third respectively in terms of higher weights. The non-breastfed babies had the lowest mean monthly weights throughout the study period.Considering the mean monthly weight gain for the three age groups, the babies within ages 0-3 months had 2.977kg while those within 4-6 and 7-9 had 1.45kg and 0.993kg respectively. This suggested that the weight gain was higher in the first three months of life and decreased through the next age groups. For the four groups of feeding practices the weight gains were respectively 3.312kg, 3.34kg, 3.015kg and 1.948kg for exclusive breastfeeding, breastfeeding with water only, breastfeeding with water and any other food and feeding without breast milk for the first three months of life. The mean weight gains for the 4th, 5th, and the 6th months were 1.354kg for exclusive breastfeeding, 1.377kg for breastfeeding with water only, 1.377kg for breastfeeding with water and any other food and 1.795kg for feeding without breast milk. The weight gains for the first six months after birth confirmed the assertion that exclusive breastfeeding is the best form of feeding for babies. The weight gains were 4.7kg for exclusive breastfeeding, 4.7kg for breastfeeding with water only, 4.4kg for breastfeeding with water and any other food and 3.7kg for non-breastfeeding. There was seemingly a drastic decrease in weight gain for babies under exclusive breastfeeding from the 7th to the 9th month which was just after introduction of complimentary food to the babies although there was general decreasing trend of weight gain. The weight gains as in the same sequence were 0.84kg, 1.06kg, 0.85kg and 1.3kg. A composite line graph of mean weights against age in months in figure 4.1 suggested such a shocking revelation of non-breastfed babies having high rate of weight gain at the latter stages of the study period. A Plot of weight by time with respect to gender indicated that males have high rate than females (fig 4.2) as the graph for male was consistently higher.A table of correlation coefficient gave strong positive correlations between any two different months. The strength of the correlation, however, declines from the closer months to the months wider apart. This prompted the use of general linear model for further analysis.An analysis of variance conducted using General linear model method revealed that age is significant in determining the weight of babies under nine months old. Thus the older the baby the heavier the baby as exposed by the increasing trend in weight by month is confirmed. At 5% significant level the one-way ANOVA revealed that there exist differences in the mean weights of babies. There was also an indication that there were significant differences in weights of the babies under the four forms of feeding practice for the first six months. For the 7th, 8th and 9th months, the analysis indicated that there were not significant differences in weights under the feeding practices.Contrary to the suggested assertion that male babies weigh more than female as revealed by the plot in fig 4.2, the analysis by the general linear model showed that sex does not influence weight gain. For all of the nine months, sex was found to be not statistically significant at 5% level. This called for further investigation. Using Repeated Measures Multivariate Analysis of variance (MANOVA), sex was found to be significant for all the statistics; Wilks Lambda, Pillais Trace, Hotelling-Lawley Trace and Roys Greatest Root at 5% level. Similarly, the MANOVA test criteria and exact F statistics for the hypothesis of no feeding practices effect confirmed again that there are differences in weights under the feeding practices. Thus, feeding practice affects the weight gain. There were no interaction effects of sexes and feeding practices on the weights.Since the measurement were repeated measurements over time on the same subject the data is a longitudinal data requiring longitudinal data analysis. Furthermore, the plot of mean monthly weight of the feeding practices against the time (age in months) illustrated longitudinal relationship in the exploratory analysis. The observations were positively correlated, which often occurs with longitudinal data, and meant that the variances of the time-independent predictor variables are underestimated if the data is analyzed as though the observations are independent. In other words the Type I error rate is inflated for these variables. For time-dependent predictor variables also, ignoring positive correlation leads to a variable estimate that is too large. In other words, the Type II error rate is inflated for these variables. Special methods of statistical analysis are needed for longitudinal data such as this because the set of measurements on one subject tends to be correlated; measurements on the same subject close in time tend to be more highly correlated than measurements far apart in time and the variances of longitudinal data often change with time. These potential patterns of correlation and variation may combine to produce a complicated covariance structure. This covariance structure must be taken into account to draw valid statistical inferences. Therefore, standard regression and ANOVA models may produce invalid results because two of the parametric assumptions (independent observation and equal variances) may not be valid as stated and documented in chapter 3 (methodology).The linear mixed model allows a very flexible approach to modeling longitudinal data. The data structure is similar to univariate ANOVA where the number of observations equals the number of measurements for all the subjects. This means the data does not have to be balanced. An advantage of fitting linear mixed model is that PROC MIXED uses all the available data in the analysis.PROC MIXED offers a wide variety of covariance structures. This enables the user to directly address the within-subject correlation structure and incorporate it into a statistical model. By selecting a parsimonious covariance model that adequately accounts for within-subject correlations, the user can avoid the problems associated with univariate and multivariate ANOVA using PROC GLM (Little, Freund and Spector, 2001).Using the information criteria in selection, it was realized that 1st order Ante-Dependence was the most appropriate covariance structure for the data for the study. In Model Information SASUSER SEX was the data set, Weight was the dependent variable, RESPONDENTS were the Subject Effect, Estimation Method employed was REML, Residual variance method was none, the Fixed Effects Standard Error Method was Model-Based and the Degrees of Freedom Method was Satterthwaite.The Dimensions for the matrices were 17 covariance parameters, 9 columns in X matrix with 0 columns in Z matrix and maximum observations per subject were 9. There were 109 subjects, 986 Number of observations read, 981 Number of observations used and 5 Number of observations not used.The iteration history indicated that convergence criteria were met, Covariance Parameter estimates were given as; respondents are the subjects; variables (1), variables (2), ,variable (9); Rho (1), Rho (2), , Rho (9) are the covariance parameters with their corresponding estimates listed respectively.AIC was the appropriate Fit statistics used to select the most appropriate covariance structure which was the Ante-dependence.The model validated the graph of the mean monthly weights in the exploratory analysis section and other assertion such as relationship between feeding practice and weight gain, initial weight (or birth weight) and weight gain and monthly weight gains. Thus, it confirmed that feeding practices affect weight of babies, birth weight affect weight of babies and monthly weight gains are different. Sex was found to be influential in weight of babies which is the biggest change. This illustrates how changing the covariance structure can change the inferences made from model.Using an output generated by General Linear Model, and judging from the contributions of each of the feeding practices to the model, the exclusive breastfeeding is found to be very significant, followed by breastfeeding with water only with non-breastfeeding and breastfeeding with water and any other food being not significant for the first six months. Furthermore, considering the solution for fixed effects, using BFWO as the base, both EBF and BFW are found not to be significant while NBF is found to be significant. 5.2 CONCLUSIONSFrom the review of the related research works, proper nutrition helps give every child the best start in life. Malnutrition of children (0-59 months) is a public health concern in Africa, particularly in the Sahelian countries. Breastfeeding has been found to reduce the occurrence of the pressing public health challenge of malnutrition. From the analyses, it is concluded that the type of feeding practice of a baby affect weight gain significantly.It is also concluded that the mean weight gain is higher in the first three months of life compare to that of 4th 6th and 7th 9th months.The birth weight of a baby has a significant influence on weight gain at the early stage of growth.The Exclusive Breastfeeding babies rate of weight gain is highest for the first six months but slows down drastically and becomes the second lowest after the introduction of complimentary foods. The non-breastfed babies have rate of weight gain to be the lowest throughout the study period. The study has therefore confirmed that Exclusive Breastfeeding is the best form of feeding practice for a baby for the first six months after birth. Comparatively, there is no clear difference in weight gain between female and male babies as there was inconsistency in the results provided by various methods of analysis.5.3 RECOMMENDATIONS1. There is need for promotion and protection of optimal infant feeding practice for improving nutrition since infant feeding practices constitute a major component of child caring practices. 2. Nursing mothers should be encouraged to frequently report at the weighing centers to facilitate the early detection of ill-health in babies and other early childhood diseases.3. The ministry of health should open more weighing centers and put up mobile teams to go round the communities to solve the unfriendly overcrowding situations in the existing ones that deter mothers from participating in the exercise.4. Educational programs on Exclusive Breastfeeding for the first six months of life should be intensified, especially by radios in order to reach the remote areas of the country.5. Parents or guardians who have babies who do not have the benefit of breastfeeding should consider timely admission to Babies Homes as urgent and important.6. The importance of adequate complementary feeding in the second half of infancy needs to be stressed in nutrition education programmes.

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