A STUDY ON THE MAGNITUDE OF

DIARRHEA IN BREAST-FED VERSUS

FORMULA-FED BABY.

DR.NARESH KUMAR S

POSTGRADUATE TRAINEE,
DEPARTMENT OF PAEDIATRICS
BURDWAN MEDICAL COLLEGE AND HOSPITAL, BURDWAN.

Dissertation submitted to the West Bengal University of Health Sciences in partial fulfilment of the
requirements for the Degree of Doctor of Medicine (M.D.) in Paediatric medicine.
Session: 2018-2021.

GUIDE

PROF. (DR.) KAUSTAV NAYEK

PROFESSOR
DEPARTMENT OF PAEDIATRICS
BURDWAN MEDICAL COLLEGE AND HOSPITAL, BURDWAN.
 CONTENTS

PAGE NO:

1. INTRODUCTION ………………………………………………

2. REVIEW OF LITERATURE …………………………………...

3. AIMS AND OBJECTIVES ……………………………………..

4. MATERIALS AND METHODS ……………………………….

5. OBSERVATION AND RESULTS ……………………………..

6. DISCUSSION …………………………………………………..

7. SUMMARY …………………………………………………….

8. CONCLUSION …………………………………………………

9. BIBLIOGRAPHY ………………………………………………

ANNEXURE I: STUDY PROFORMA.........................................

ANNEXURE II: PARENT INFORMATION SHEET ……………

ANNEXURE III: INFORMED ASSENT FORM ………………...

ANNEXURE IV: INFORMED CONSENT FORM ………………

ANNEXURE V: KEYS TO MASTER CHART ………………………….

ANNEXURE VI: MASTER CHART ………………………………………….

Introduction
Breastfeeding is an unparalleled way of providing ideal food for the

healthy growth and development of infants1.

Breast milk upregulates sensory as well as cognitive development,

and safeguards the infant against infectious and chronic diseases2. Infant

mortality due to common childhood illnesses such as diarrhea is reduced

by breastfeeding, and it helps for a quicker recovery during illness3.

Breast milk contains all nutrients as well as antibodies especially

Immunoglobulin A (IgA), and protects baby from infections including

diarrheal diseases4. WHO has recommended, infants should be

exclusively breastfed for the first six months of life to achieve optimal

growth, development and health. Breast milk substitutes (such as

commercial infant formulas and cow's milk) are considered nutritionally

acceptable for few infants, but there is greater risk of developing a

number of infections, including diarrhea5. Breast milk substitutes and

other baby foods, as well as bottles, teats and utensils, are attributable to

contamination causing diarrheal diseases in infants who are not

exclusively breastfed6.

Breastfeeding offers an excellent opportunity to find out how the

mother is getting along with her baby, particularly with regard to

feeding. Breast milk provides the most vital source of nourishment in the

first year of life. In some societies, lactation continues to make an

important contribution to the child's nutrition for 18 months or longer.

In the world's more affluent societies, breastfeeding appears to have

become a lost art, and the feeding bottle has usurped the breast. When

the quality of sanitation is poor and the level of education low, the

content of the feeding bottle is likely to be as nutritionally poor as it is

bacteriologically dangerous. It is therefore very important to advise the

mothers to avoid the feeding bottle.

One of the greatest assets in India is that an ordinary Indian mother,

even if she is poor in nutritional status, has a remarkable ability to

breastfeed her infant for prolonged periods, sometimes extending to

nearly two years and beyond.

Longitudinal and cross-sectional studies indicate that poor Indian

women secrete as much as 400 to 600 ml of milk per day during the first

year. No other food is required to be given until six months after birth.

At the age of 6 months, breast milk should be supplemented by

additional foods rich in protein and other nutrients (e.g., animal milk,

soft cooked mashed vegetables, etc.). These are called supplementary

foods, which should be introduced very gradually in small amounts.

 A child who is breastfed has greater chances of survival than a child

artificially fed. Prolonged breastfeeding does protect the infant from

early malnutrition and some infections. The data suggest that infant

mortality rates in developing countries are five to ten times higher

among children who have not been breastfed or who have been breastfed

for less than six months. Despite the marked advantages of

breastfeeding, its popularity has declined significantly in many parts of

the world.

Early initiation of breastfeeding lowers the mother's risk of postpartum

hemorrhage and anemia, boosts the mother's immune system, delays the

next pregnancy, and reduces the insulin of diabetic mothers. It protects

mothers from ovarian and breast cancers and osteoporosis. There is a

misconception among several women that breastfeeding spoils the figure

and shape of breasts. On the contrary, breastfeeding helps to maintain

and regain the pre-pregnancy bodyweight earlier because energy stores

laid down during pregnancy are consumed faster during lactation. As far
as the shape of the breasts is concerned, there is no difference whether

the mother breastfeeds or gives formula feeds to her baby.

The advantages of breast feeding are hereby summarized

1) it is safe, clean, hygienic, cheap and available to the infant at correct

temperature 2) it fully meets the nutritional requirements of the infant in

the first few months of life 3) it is easily digested and utilized by both

the normal and the premature babies 4) promotes bonding between the

mother and the infant 5) sucking is good for the baby – helping in the

development of teeth and jaws 6) it protects the babies from tendency to

obesity 7) it prevents malnutrition and reduces infant mortality 8) it

provides several biochemical advantages such as prevention of neonatal

hypocalcemia and hypomagnesemia 9) it helps the parents to space their

children by prolonging the period of infertility 10) special fatty acids in

breast milk lead to increased intelligence quotients and better visual

acuity. A breastfed baby is likely to have an I.Q. of around 8 points

higher than a non-breastfed baby. 11) it contains antimicrobial factors

such as macrophages, lymphocytes, secretory IgA, anti streptococcal

factor, lysozyme, and lactoferrin, which provide considerable protection

not only against diarrheal diseases and necrotizing enterocolitis, but also

against respiratory infections in the first months of life. 12) The risk of

cot death or sudden infant death syndrome is less in breastfed babies.

Neither is it necessary nor desirable to stimulate or train a baby to

be fed by the clock. It should be thoroughly explained to the mother,

however, that time gap between feeds are necessary for herself and for

the baby, though they may vary between 1 to 4 hours , according to the

baby's needs, size, strength of sucking and the mother's milk supply.

However, an artificial feed can be given in case of failure of breast

milk, prolonged illness, or death of the mother. It is crucial for the baby

to be fed breast milk substitutes - e.g., dried whole milk powder, fresh

milk from a cow, or other animal or commercial formulae.

Rationale of this study:

Many studies have been conducted earlier on the magnitude of diarrhea

in breastfed, in comparison with the formula-fed babies, but the

predisposing and the relating factors which cause diarrhea in these

babies have not been dealt properly. With this in mind, the present study

was planned to assess the magnitude of diarrhea in the breastfed and the

formula fed babies in relation to the occupation of the parents,

educational qualification of the parents, type of housing they live in,

water supply, and sanitary facilities, which may directly pre-dispose to

diarrhea.
Review of

literature
BREAST FEEDING:

The human baby, like the offsprings of other mammals, is born with a

ready-made food supply of its own, and therefore breastfeeding is

natural and instinctive. The milk of different animals is uniquely

species-specific, and its composition is adapted to the needs of the baby.

The lowest protein content of human milk is in keeping with the slowest

rate of growth of a human infant.

COMPOSITION OF HUMAN MILK :

The composition varies depending upon the genetic background or

ethnic factors, age, parity, nutritional status, and dietary intake of the

mother. It also varies depending upon the timing of delivery (term or

preterm), duration of the lactation, time of the day (diurnal variations),

frequency of feeding, and whether it is foremilk or hindmilk. Breast milk

of malnourished women may be suboptimal in quantity and quality, with

lower concentrations of fat, water soluble vitamins, vitamin A and

calcium. In a healthy, well-nourished nursing mother taking a balanced

diet, exclusive breastfeeding can serve all the nutritional needs of the

baby, except vitamin K and vitamin D, which are relatively deficient.

MACRONUTRIENTS IN BREAST MILK:

Total energy content : 67 kcal

Carbohydrate content : 7 gm%

Protein content : 1.1 gm%

Fats : 3.5 gm %

CARBOHYDRATES:

Human milk has the highest concentration of lactose (7gm/dl) compared

to all other mammals. Human milk is sweeter and thinner compared to

the animal milk because of the higher concentration of lactose and lower

content of solids. The baby breaks lactose into two simple sugars

glucose and galactose. The latter is credited to enhance the production of

cerebrosides and growth of neurons. Oligosaccharides are unique to

human milk and are present in high concentrations (0.7-1.2 g/dl). The

most common sugars making up these short-chain oligosaccharides

include N acetyl D glucosamine, sialic acid, and fucose.

PROTEINS :

Human milk has the lowest concentration of protein (1.1g/dl) among all

mammals. It accounts for 75% of nitrogen-containing compounds in

breast milk. Human breast milk is whey predominant. It contains whey

and casein in the ratio of 80:20. Most important proteins in the breast

milk are alpha-lactoalbumin, lactoferrin, IgA, beta-casein. Aminoacids

in the breast milk are taurine, cysteine, tryptophan. Taurine and cysteine

are important for brain growth, and tryptophan is converted into

serotonin, which is an important neurotransmitter in the brain. Most of

the amino acids in breast milk are in "trans" form, which is

advantageous to the baby.

FATS:

Fat content of human milk is relatively lower (3.4 g/dl) compared to the

milk of other animals, but nevertheless, it provides 50% calories from

lipids. About 98% of lipids in milk are triglycerides and small amounts

as di- and mono glycerols, cholesterol, fatty acids, and phospholipids.

Breast milk is rich in essential fatty acids and polyunsaturated fatty acids

like linolenic acid and linoleic acid. Linolenic acid forms

docosahexanoic acid (DHA), and linoleic acid forms arachidonic acid.

Both are important for brain growth. Essential fatty acids are important
for myelination.

IMMUNOBIOLOGY OF BREAST MILK :

Breast milk is the first immunisation the baby receives. It contains:

1. IgA, which protects the gastrointestinal and respiratory epithelium.

Baby who is breastfed is 14 times less likely to die of respiratory

infection, four times less likely to die of diarrhea (G.I. infections), 2

to 5 times less likely to die of other infections.

2. Lactoferrin, which inhibits E.coli infection by preventing its binding

to G.I. epithelium.

3. Lysozyme, which kills bacteria, specifically gram positive bacteria

and have a protective role against HIV .

4. Para amino benzoic acid (PABA), which protects the child from

malarial infection.

5. Bifidus factor, which protects against E.coli

6. Bile salt stimulated lipase, which protects against parasitic infections

like amoebiasis, giardiasis.

7. Human alpha lactalbumin, which protects the child against tumours,

particularly reduces the risk of leukemia and breast cancer.

8. Platelet activating factor-alpha hydrolase, which is a potent anti-

inflammatory agent, protects against necrotizing enterocolitis (NEC).

9. Growth factors like Epidermal growth factor and transforming

growth factor B, which reduces the risk of allergy and augments IgA

production respectively

10. Galacto Oligosaccharides , which inhibits the attachment of

bacteria to the G.I. tract.

TYPES OF BREAST MILK :

COLOSTRUM :

It is secreted in the first three to four days after delivery. It is very thick

and yellowish and produced in very small quantity. It is rich in

antibodies and contains fat-soluble vitamins A,D,E,K and PUFA.

TRANSITIONAL MILK :

It is secreted after three to four days until two weeks after delivery. Its

fat content reduces, and protein and calorie content increase.

MATURE MILK:

After two weeks, mature milk is produced. Mature milk has

FORE-MILK, which is more watery and quenches thirst. It is rich in

protein and sugar.

HIND-MILK, which is thick and rich in fat.

Comparison of the nutritional value of term milk and preterm milk

carbohydrate-7gm carbohydrate-6gm
% %

protein-2gm%
protein-1gm
%

fat-3.5gm fat-3.5gm%
%

TERM MILK PRE-TERM MILK

DIARRHEA :

Passage of loose, liquid or watery stools. These liquid stools are passed
more than three times a day. However, it is the recent change in
consistency and character of stools rather than the number of stools that
is more important

Term "diarrheal diseases" should be considered only as a convenient

expression- not as a nosological or epidemiological entity- for a group of

diseases in which the predominant symptom is diarrhea.

CLINICAL TYPES:

1) ACUTE WATERY DIARRHEA:

Lasts for several hours to days. The main danger is dehydration, and

weight loss also occurs if feeding is not continued. The pathogens that

usually cause acute diarrhea include V.cholerae or E.coli bacteria, as

well as rotavirus.

ACUTE BLOODY DIARRHEA :

Also called Dysentery. The main dangers are the damage of the

intestinal mucosa, sepsis, and malnutrition; other complications

including dehydration, may also occur. It is marked by visible blood in

stools. The most common cause of bloody diarrhea is shigella, a bacteria

that is also a most common cause of several cases.

PERSISTENT DIARRHEA:

Lasts for 14 days or longer. The main danger is malnutrition and serious

non intestinal infection, dehydration may also occur. Persons with other

illness, such as AIDS, are more likely to develop persistent diarrhea

DIARRHEA WITH SEVERE MALNUTRITION (MARASMUS ANS

KWASHIORKAR :

The main dangers are severe systemic infection, dehydration, heart

failure, and vitamin and mineral deficiency.

GASTRO-ENTERITIS:

GASTROENTERITIS denotes inflammation of the gastrointestinal

tract, most commonly the result of infections with bacterial, viral, or

parasitic pathogens . Many of these infections are foodborne illnesses .

BURDEN OF CHILDHOOD DIARRHEA :

Although global mortality due to diarrheal diseases has declined

substantially (39%) during the past two decades, it remains unacceptably

high. In 2015, the diarrheal diseases caused an estimated 499,000, or

8.6%of all childhood deaths, making it the 4th most common cause of

child mortality worldwide. Over the same period, a smaller decline

(10%) was observed in the incidence of diarrhea disease among children

younger than 5 yr. Almost 1.0 billion episodes occurred in 2015

worldwide, resulting in an estimated 45 million childhood disability-

adjusted life years. Approximately 86% of the episodes occurred in

Africa and South Asia (63% and 23%, respectively). The decline in

diarrheal mortality, despite the lack of significant changes in incidence,

is the result of preventive rotavirus vaccination and improved case

management of diarrhea, as well as improved nutrition of infants and

children.

These interventions have included widespread home- and hospital-based

oral rehydration solution (ORS) therapy and improved nutritional

management of children with diarrhea.

In addition to the risk of mortality, high rates of diarrhea can be

associated with long-term adverse outcomes. Diarrheal illnesses,

especially episodes among young children that are recurrent, prolonged,

or persistent, can be associated with malnutrition, stunting, micronutrient

deficiencies, and significant deficits in psychomotor and cognitive

development.

Acute diarrhea is rivalled in importance only by respiratory infections,

as a cause of morbidity on a worldwide scale. When the WHO initiated

the Diarrhoeal Diseases Control Programme in 1980, approximately 4.6

million children used to die each year of the dehydration caused by

diarrhoea. Diarrhoea is still a major killer of children under 5. although

its toll has dropped by a third over the past decade. It killed more than

1,300 children under 5 years of age every day in 2016. It accounts for 8

percent of all under-five deaths - a loss of more than 0.48 million child

lives in 2016. Most of these deaths occur among children less than two

years of age (2). Comparing estimates of the current global burden of

diarrhoeal disease with previously published estimates, highlights that

the incidence of diarrhoea have not changed much, although overall

diarrhoeal mortality has declined. For children aged under 5 years, a

median of 3 episodes of diarrhoea occurred per child-year, which is

similar to that reported previously. The current estimates in under-five

children suggest that there are about 1. 7 billion episodes of diarrhoea

per year with 123 million clinic visits annually and 9 million

hospitalizations worldwide, with a loss of 62 million disability-adjusted

life years (DALYs) (3).

In India, acute diarrhoeal disease accounts for about 10 percent of deaths

in under-5 years age group. During the year 2017, about 12.92 million

cases with 1,331 deaths were reported in India (4).

Diarrhoea becomes an important cause of mortality during complex

emergencies including natural disasters. Displacement of population into

temporary, overcrowded shelters is often associated with polluted water

sources, inadequate sanitation, poor hygiene practices, contaminated

food and malnutrition - all of which affect the spread and severity of

diarrhoea. At the same time, the lack of adequate health services and

transport reduces the likelihood of prompt and appropriate treatment of

diarrhoea cases.

Diarrhoeal disease causes a heavy economic burden on the health

services. Much attention has been given to acute diarrhoeal disease and

its management over the last decade, which is dominated by advances in

oral rehydration technique and through integrated management of

childhood illness. The treatment recommendations reflect a better

understanding of what works to reduce child death from diarrhea, as

well as newer insights into the treatment feasibility. These changes in

treatment recommendations and preventive measures have subsequently

led to monitorable treatment and diarrhea prevention indicators.

They are as follows (5) :

The Indian data generated by demography and health survey 2005-2006

is given in bracket with each indicator.

(A) Diarrhoea prevention indicators

(1) Percentage of population using:

(a) improved drinking water sources (urban, rural, total); (For India -

urban 97% , rural 90% and total 92%)

(b) improved sanitation facilities (urban, rural, total); (For India - urban

58%, rural 23% and total 34%)

(2) Percentage of one year old immunized against measles; (lndia-74%)

(3) Percentage of children who are :

- under-weight (moderate and severe) - 0 to 59 (India-43%) months age

- stunted (moderate and severe) - 0 to 59 (lndia- 38. 7%) months age

- exclusively breast-fed - 0 to 5 (India-46%) months age

- breast-fed with complementary - 6 to 9 food (lndia-57%) months age

- still breast-feeding - 20 to 23 (India-77%) months age

(4) Vitamin A supplementation coverage rate (percent full coverage) - 6

to 59 months (India-53%)

(B) Diarrhoea treatment Indicators

Percentage of children under five years with diarrhea receiving:

(1) ORT with continuous feeding (India 33%)

(2) ORS packet (India 26%)

(3) Recommended home made fluids (India 20%)

(4) Increased fluids (India 10%)

(5) Continued feeding (India 70%)

(C) Use of oral rehydration therapy

Percentage of children under-five years with diarrhea receiving oral

rehydration therapy (ORS packet or recommended home-made fluids or

increased fluids with continued feeding)

(1) Gender - male, female (India - male 34%, female 31 %)

(2) Residence - Urban, rural (India - urban 38%, rural 31 %)

(3) Wealth index quintiles - poorest, second, middle, fourth, richest

(India - 29%, 29%, 3 1 %, 35% and 45%).

Diarrhoea is most common in children, especially those between 6

months and two years. Incidence is highest in the age group 6-11

months, when weaning occurs. It reflects the combined effects of

declining levels of maternally acquired antibodies, the lack of active

immunity in the infant, the introduction of contaminated food, and direct

contact with human or animal faeces when the infant starts to crawl. It is

also common in babies under six months of age fed on cow's milk or
infant feeding formulas (16). Diarrhoea is more common in persons with

malnutrition. Malnutrition leads to infection and infection to diarrhoea

which is a well known vicious circle. Poverty, prematurity, reduced

gastric acidity, immunodeficiency, lack of personal and domestic

hygiene and incorrect feeding practices are all contributory factors.

EPIDEMIOLOGY IN LOW- AND MIDDLE-INCOME

COUNTRIES

The Global Enteric Multicenter Study (GEMS) evaluated children

younger than 5 yr living in 7 low-income countries in sub-Saharan

Africa and South Asia and seeking healthcare for moderate-to-severe

diarrhea. Although a broad array of pathogens were identified, most

episodes of moderate-to-severe diarrhea were attributed to 4 pathogens:

rotavirus, Cryptosporidium, Shigella, and ETEC producing heat-stable

toxin (S.T.) either alone or in combination with heat-labile toxin (L.T.),

herein termed ST-ETEC, and, to less extent, adenovirus 40 and 41. On

the other hand, several etiologic agents that are common causes of AGE
in high-resource settings are notable for their low frequency in resource-

limited settings: NTS, STEC, norovirus, and C. difficile toxin. The 3

agents associated with most deaths among children under 5 yr are

rotavirus (29%), Cryptosporidium (12%), and Shigella (11%). The

Etiology, Risk Factors, and Interactions of Enteric Infections and

Malnutrition and the Consequences for Child Health and Development

Project (MAL-ED) was a study of less severe, community-based

diarrhea. Viral causes predominated (36.4% of the overall incidence),

but Shigella had the single highest attributable incidence (26.1

attributable episodes per 100 child-years).

Abdulbari Bener et al. study on exclusive breastfeeding and

prevention of diarrheal diseases showed more than half of the infants

(59.3%) were exclusively breastfed; the risk for presenting diarrhea was

higher in formula-fed (48.7%) and partially breastfed children (37.3%)

when compared to exclusively breastfed (32.5%)7.

 Black RE et al. in a study8 on Maternal and child undernutrition

showed that the relative risk for the prevalence of diarrhea was more in

predominant and partial breastfeeding (1.26 and 3.04, respectively) as

compared to exclusive breastfeeding.

World Health Organization (WHO) recommends exclusive

breastfeeding for the first six months of life and continuation of

breastfeeding for two years or beyond9,10.

Laura M Lamberti et al.11 study on breastfeeding and the risk for

diarrhea morbidity and mortality showed an excess risk of diarrhea in

non-exclusively breastfed 0-5 months aged infants; relative risk of

diarrheal incidence was 1.26, 1.68, and 2.65 in predominant, partial, and

non-breastfed group children respectively.

RISK OF NOT BREASTFEEDING LEADING TO DIARRHEA:

RELATIVE RISKS OR ODDS RATIOS AND 95% CONFIDENCE

INTERVALS.

DIARRHEAL DIARRHEAL

MORBIDITY MORTALITY
NO BREAST RR = 2.7 (1.7-4.1) RR = 10.5 (2.8-39.6)
compared with compared with
FEEDING (0-5
exclusive exclusive
MONTHS)
breastfeeding breastfeeding
NO BREAST RR = 1.3 (1.1-1.6) RR = 2.2 (1.1-4.2)
FEEDING (6-23 compared with any compared with any
breastfeeding breastfeeding
MONTHS)
Aims and

objectives
AIM :

The present study has been planned with the aim to study the magnitude

of diarrhea in breastfed versus formula-fed babies.

OBJECTIVE :

PRIMARY OBJECTIVE :

This present study is to find out the magnitude of diarrhea in breastfed

babies in comparison with the formula-fed babies taking into account the

parameters like age group, sex, sanitation, water supply, type of

residence they live in, father's educational qualification (and) occupation

and mother's educational qualification (and) occupation.

Methodology
STUDY TYPE: An observational type of descriptive epidemiological

study.

STUDY DESIGN- Hospital based observational cross-sectional study.

STUDY SETTING AND TIMELINES-

 PREPARATORY PHASE-1st September 2018 to 15th October

2018.

 DATA COLLECTION PHASE-1st January 2019 to 31st

December 2019.

 DATA ANALYSIS PHASE-1st January 2020 to 30th April 2020.

 REPORT WRITING PHASE-1st May 2020 to 31st August 2020.

PLACE OF STUDY- Paediatric indoor ward and paediatric outpatient

department, Department of Paediatrics, Burdwan medical college and

hospital, Burdwan .

PERIOD OF STUDY- 1st September 2018 to 31st August 2020.

STUDY POPULATION- Children, aged 1 to 24 months having

diarrhea, attending the department of pediatrics, BMCH, both in and

outpatient, who met the inclusion criteria.

SAMPLE SIZE - 200 children under two years of age and more than

one month of age. Samples were selected by random sampling

method.
INCLUSION CRITERIA-

Children aged 1 to 24 months, having diarrhea, i.e., watery stools (type 6

and 7 stools in Bristol stool chart) for more than three episodes per day,

were included in the study.

EXCLUSION CRITERIA-

1) Children aged less than one month or more than 24 months

2) Children with less than three episodes of loose stools per day.

3) Children whose mother refused to give consent for the study.

4) Severely dehydrated and seriously ill children.

STUDY VARIABLES :

1) Socio-epidemiological data (age,sex,district,religion)

2) Data regarding feeding information.

3) Data regarding the number of diarrheal attacks.

4) Data regarding the age of the first occurrence of diarrhea.

5) Data regarding the formula feeding utensils.

6) Data regarding the water supply.

7) Data regarding the type of residence.

8) Data regarding the education of parents.

9) Data regarding the occupation of parents.

DESCRIPTION OF THE VARIABLES:

AGE: Age was calculated in completed years as in record book.

GENDER: Mentioned as male and female

RELIGION: Religion was recorded as Hinduism, Islam, and

Christianity

CASTE: Mentioned as general, scheduled caste, and scheduled tribe.

WATER SUPPLY: Mentioned as tube well and tap water.

RESIDENCE: Mentioned as urban, rural, and urban-slum.

SANITATION: Mentioned as pucca, water-seal, Katcha, and open air.

EDUCATIONAL STATUS of PARENTS: It was noted as:

Illiterate: Cannot read and write

Non-formal literate: Have not done any schooling but can read and write

Primary: Class I-IV

Middle school: Class V-VIII

Secondary: Class IX-X

Higher Secondary: Class XI-XII

College Level: Have gone to college but have not completed graduation

Graduate: Have completed graduation

PARENTS' OCCUPATION:

Occupation of the parents was categorised as per Modified

Kuppuswamy socio-economic status scale for occupational category :

1. Skilled worker- Skilled employee is one who is capable of working

independently and efficiently and turning out accurate results. He must

be capable of reading and working on simple circuits and processes, if

necessary, e.g., heavy motor vehicle driver, accountant, cashier,

storekeeper, head clerk, farmer, etc.

2. Semi-skilled worker- Semi-skilled employee is one who has

sufficient knowledge of the particular trade or above to do respective

work with the help of simple tools and machines, e.g., sorter/checker,

light motor vehicle drivers

3. Unskilled worker-Unskilled employee is one who possesses no

special training and whose work involves the performance of simple

duties which require the exercise of little or no independent judgement

or previous experience although a familiarity with the occupational

environment is necessary e.g. loader, unloader, puda maker, chowkider

4. Unemployed-Currently retired and not employed in any job at

present.

5. Professional- Professional Employee is the one who is involved in

decision making, formulating policies, execution of policies. e.g.

Medical officers, Engineers.

STUDY TOOLS :

A pre-designed and pre-tested structured close-ended questionnaire

containing information regarding demographic data was used; detailed

feeding history and information of diarrhea was taken.

STUDY TECHNIQUES:

1) Face to Face interview using a structured close-ended questionnaire

containing information regarding demographic data, detailed feeding

history, and information of diarrhea.

2) Clinical examination of the patient.

DATA COLLECTION :

Data was collected by using the questionnaire with prior permission of

the care givers by getting informed written consent from them.

STATISTICAL ANALYSIS:

Collected data was entered in Microsoft excel work sheet and was

double checked for accuracy. Data was then analyzed using Student's t,

Chi-square and repeat measurement tests. Statistical analysis was

carried out using SPSS software, version 11.5.

Data is presented in the form of diagrams and tables. Bar and Pie

diagrams was used for discrete/categorical data. Categorical data is

expressed in proportions. Continuous data and dispersion of data, was

expressed in mean values and S.D respectively .

OUTCOME VARIABLES :

The magnitude of diarrhea in children is studied in relation to the

1) age group

2) type of feeding (breast feeding or formula feeding or both)

3) type of feeding utensil used

4) type of water supply

5) type of sanitation
6) type of residence

7) educational qualification of the parents

8) Occupation of the parents

ETHICAL CLEARANCE:

At first, the proposal was submitted for ethical clearance to institutional

ethics committee of our college.

Data collection was initiated only after receiving the ethical clearance

certificate. Informed written consent was taken from caregivers of each

children.

Strict privacy and confidentiality was maintained throughout the study.

Identity of participants will not be disclosed .

Conflict of interest:

There is no conflict of interest in this study.

Observation

and

Results
 Age of the population ranges from 1 month to 23 months . Mean age

was 10.98 months with standard deviation of ± 5.49 months .

Demography of the study population is as follows :

AGE DISTRIBUTION :

AGE GROUP : NUMBER

1 to 6 months 40

7 to 12 months 80

13 to 18 months 62

19 to 24 months 18

1-6 months (20%)

7-12 months (40%)
13-18 months (31%)
19-23 months (9%)
SEX DISTRIBUTION :

SEX NUMBER

Male 136

Female 64

FEMALE
32%

MALE
68%
SANITATION :

PUCCA 126

WATER SEAL 20

KUTCHA 50

OPEN AIR 4

OPEN AIR
2%

KATCHA
25%

WATERSEAL
10% PUCCA
63%
RESIDENCE :

URBAN 86

RURAL 106

URBAN SLUM 8

URBAN SLUM
4%

URBAN
43%

RURAL
53%
WATER SUPPLY :

TUBE WELL 174

TAP WATER 26

TAP WATER
13%

TUBE WELL
87%
MOTHER'S EDUCATION :

ILLITERATE - 20

NON FORMAL LITERATE - 10

PRIMARY - 40

MIDDLE - 32

SECONDARY/HIGH - 72

HIGHER SECONDARY/POST HIGH - 20

COLLEGE LEVEL - 4

GRADUATE - 2
HIGHER
SECONDARY/POST COLLEGE LEVEL GRADUATE ILLITERATE
HIGH 2% 1% 10%
10%
NON FORMAL LITERATE
5%

PRIMARY
SECONDARY/ 20%
HIGH
36%

MIDDLE
16%

FATHER'S EDUCATION :
ILLITERATE – 26

NON FORMAL LITERATE – 4

PRIMARY – 22

MIDDLE – 22

SECONDARY/HIGH – 64

HIGHER SECONDARY/POST HIGH – 20

COLLEGE LEVEL – 40

GRADUATE – 2

GRADUATE
1% ILLITERATE
COLLEGE LEVEL 13%
20% NON FORMAL LIT-
ERATE
2%

PRIMARY
HIGHER 11%
SECONDARY/POST
HIGH
10% MIDDLE
11%

SECONDARY/
HIGH
32%
MOTHER'S OCCUPATION :

SKILLED - 28

SEMI SKILLED - 12

UNSKILLED - 56

UNEMPLOYED - 104

PROFESSIONAL -0

SKILLED
14% SEMI SKILLED
6%

UNEMPLOYED
52%

UNSKILLED
28%
FATHER'S OCCUPATION :

SKILLED - 76

SEMI SKILLED - 68

UNSKILLED - 54

UNEMPLOYED -0

PROFESSIONAL -2

PROFESSIONAL
1%

UNSKILLED
27% SKILLED
38%

SEMI SKILLED
34%
TYPE OF FEEDING :

EXCLUSIVE BREAST FEEDING - 100

BREAST FEEDING + FORMULA FEEDING - 79

EXCLUSIVE FORMULA FEEDING - 21

EFF
11%

EBF
50%
BF+FF
40%
FIRST OCCURRENCE OF DIARRHEA :

1 – 6 MONTHS - 80

7 – 12 MONTHS - 84

13 – 24 MONTHS - 36

13-24 MONTHS
18%

1-6 MONTHS
40%

7-12 MONTHS
42%
FREQUENCY OF DIARRHEAL ATTACKS :

SINGLE ATTACK - 113

TWO OR MORE ATTACKS – 87

TWO OR MORE ATTACKS

3%

SINGLE ATTACK
97%
FORMULA FEEDING UTENSIL :

BOTTLE - 76

CUP AND SPOON – 24

CUP AND SPOON

24%

BOTTLE
76%
Fig 1 : Relationship between feeding and the number of diarrheal

attacks.

100%
25
90%

80%
47
70% 15

60%

50%
75
40%

30%
32
20% 6

10%

0%
EBF BF+FF EFF

single attack 2 or more attacks

Figure 1 shows ,single attack of diarrhea occurred in 75 (75%) ,

32 (40.5%) and 6 (28.6%) children in exclusively breast fed, breast fed

plus formula fed and exclusively formula fed group respectively.

Frequent (≥2) attacks of diarrhea occurred in 25 (25%) , 47 (59.5%) and

15 (71.4%) children in exclusively breast fed, breast fed plus formula

fed and exclusively formula fed group respectively (p value .000).

Table 1 : Type of feeding versus age of first occurrence of diarrhea.

Column1 Column2 Column3 Column4 Column5

AGE OF FIRST OCCURENCE FEEDING TOTAL
EBF BF +FF EFF
1-6 MONTHS 8(20%) 26(65%) 6(15%) 40
7-12 MONTHS 37(46.25%) 34(42.5%) 9(11.25%) 80
13-24 MONTHS 55(68.75%) 19(23.75%) 6(7.5%) 80

Table 1 shows,patients who developed first attack of diarrhea by 6

months of age were 8 (20%) from exclusive breast fed , 26 (65%) from

breast fed plus formula fed and 6 (15%) from exclusive formula fed

group. Patients who developed diarrhea by 7 to 12 months of age are 37

(46.25%) , 34 (42.5%) and 9 (11.25%) from exclusive breast fed ,

breast fed plus formula fed and exclusive formula fed groups

respectively. 80 patients developed diarrhea by 13 to 24 months of age ;

among them 55 (68.75%) , 19 (23.75%) and 6 (7.5%) were from

exclusively breast fed, breast fed plus formula fed and exclusive formula

fed groups respectively (pvalue .000).

Table 2 : Relation between mother's education and the frequency of

diarrheal attacks.

MOTHER'S EDUCATION SINGLE ATTACK 2 OR MORE ATTACKS TOTAL

ILLITERATE 7 (35%) 13 (65%) 20

NONFORMAL LITERATE 4 (40%) 6 (60%) 10

PRIMARY 22 (55%) 18 (45%) 40

MIDDLE 18 (56.25%) 14 (43.75%) 32

HIGH 43 (59.7%) 29 (40.3%) 72

HIGHER SECONDARY 14 (70%) 6 (30%) 20

COLLEGE LEVEL 3 (75%) 1 (25%) 4

GRADUATE 2 (100%) 0 2

TOTAL 113 87 200

Table 3 : Relation between water supply and frequency of diarrheal

attacks.

WATER SUPPLY SINGLE ATTACK 2 OR MORE ATTACKS TOTAL

TUBE WELL 100 (57.5%) 74 (42.5%) 174

TAP WATER 13 (50%) 13 (50%) 26

TOTAL 113 87 200

Table 4 : Relation between residence and the frequency of diarrheal

attacks .

RESIDENCE SINGLE ATTACK 2 OR MORE ATTACKS TOTAL

URBAN 45 (52.3%) 41 (47.7%) 86

RURAL 65 (61.3%) 41 (38.7%) 106

URBAN SLUM 3 (37.5%) 5 (62.5%) 8

TOTAL 113 87 200

Table 5 : Relation between formula feeding utensil and the frequency of

diarrheal attacks.

FEEDING UTENSIL SINGLE ATTACK 2 OR MORE ATTACKS TOTAL

BOTTLE 29 (38%) 47 (62%) 76

CUP AND SPOON 9 (37.5%) 15 (62.5%) 24

TOTAL 38 62 100
Table 2 shows,the children of illiterate mother had more frequent

diarrheal attacks (65%) than other literate mothers. Two or more

diarrheal attacks are seen in 60 % of children with nonformal literate

mothers , 45% of children with mothers of primary school education ,

43.75% of children with mothers of middle school education , 40.3 % of

children with mothers having high school education , 30% of children

with mothers having higher secondary education and 1% of children

with mothers who have attended college. But educational levels did not

consistently influence the occurrence and frequency of diarrheal attack

on the study population (p value .02).

Table 3 shows, 42.5% of children who have tube well as the source of

water supply had frequent diarrheal attacks when compared to 50% of

children with frequent diarrheal attacks with tap water as the water

supply. There is no significant influence of source of water on diarrheal

attack and frequency in different groups of patients (pvalue .407).

Table 4 shows , 47.7% , 38.7% , 62.5% of children living in urban ,

rural , urban slum respectively had frequent diarrheal attacks. Residence

of the patients did not influence the frequency of diarrheal attacks (p

value 0.084).

Table 5 shows , 62% of formula feeding children who use Bottle as the

formula feeding utensil had frequent diarrheal attacks when compared to

62.5 % of formula feeding children who use cup and spoon as the

formula feeding utensil and having frequent diarrheal attacks . There is

no significant influence of feeding utensil and the frequency of diarrheal

attacks in this study.

Discussion
DESIGN AND SETTING OF THE STUDY :

Breast milk is the ideal food for an infant's first six months of life.

Colostrum and breast milk contains an abundant amount of IgA2 and

other antibodies that can help the baby to resist infections. Breastfeeding

has many health benefits for both the mothers and infants. In addition to

providing ideal nourishment, breastfeeding provides infants with

protection from many infections, including diarrheal diseases.

Breastfeeding can also reduce the severity, duration, and negative

nutritional consequences of diarrhea. On the other hand, use of formulas

including infant formula is associated with increased health risks such as

acute gastroenteritis, otitis media, severe lower respiratory tract

infections, atopic dermatitis, asthma and obesity. The infant's

intestine is not properly ready to digest non-human milk and this may

often result in diarrhea, intestinal bleeding and malnutrition.

Many studies have been conducted previously on the magnitude of

diarrhea in breast fed, in comparison with the formula fed babies but the

predisposing and the relating factors which causes diarrhea in these

babies have not been dealt properly. With this in mind the present study

was planned to assess the magnitude of diaarhea in the breast fed and the

formula fed babies in relation to the occupation of the parents,

educational qualification of the parents, type of housing they live in,

water supply , feeding utensil and sanitary facilities which may directly

pre-dispose to diarrhea.

DESCRIPTION OF THE STUDY POPULATION :

A total of 200 children with diarrhea were included in the study

conducted over the period of 1 year and 7 months from 1st september

2018 to 30 th April 2020. Subjects were included only after getting the

informed consent and details were recorded as per attached proforma.

BASELINE CHARACTERISTICS OF CHILDREN INVOLVED :

In our study, the age of the population ranges from 1 month to 23

months with mean age of 10.98 ± 5.49 months . 20 % population were

under 6 months . Out of 200 children 68% (136) were males and 32%

(64) were females. 50% children (100) were exclusively breast fed , 11%

(21) were exclusively formula fed and 39% (79) were both breast fed

and formula fed.

In our study, we found that half (50%) of the study population were

exclusively breastfed and single attack of diarrhea occurred in all

children (as per inclusion criteria). But frequent (two or more) attack of

diarrhea occurred mostly in non-exclusive breast fed children; in breast

fed plus formula fed children 47 (59.5%), exclusively formula fed 15

(71.4%) and exclusively breast fed 25 (25%).

 Abdulbari Bener et al. study on exclusive breast feeding and

prevention of diarrheal diseases showed more than half of the infants

(59.3%) were exclusively breastfed; the risk for presenting diarrhea was

higher in formula fed (48.7%) and partially breastfed children (37.3%)

when compared to exclusively breast fed (32.5%).

Black RE et al. study on Maternal and child under nutrition

showed, the relative risk for prevalence of diarrhea was more in

predominant and partial breastfeeding (1.26 and 3.04 respectively) as

compared to exclusive breastfeeding.

World Health Organization (WHO) recommends exclusive breast

feeding for first six months of life and continuation of breast feeding for

two years or beyond. We found 40 patients developed first attack

of diarrhea by 6 months of age, of whom most children were from non-

exclusively breast fed group; there were breast fed plus formula fed
children 26 (65%), exclusively formula fed 6 (15%) and exclusively

breast fed only 8 (20%). This finding reflects exclusive

breastfeeding has influence on prevention of early occurrence of

diarrhea. On the other hand, patients who developed first attack of

diarrhea by 7-12 months and 13-24 months of age mostly were from

exclusively breast fed group (46.25%, and 68.75%) respectively)

indicating later occurrence of diarrhea in exclusively breast fed children

than non- exclusively breast fed one. Our finding correctly supports

current WHO recommendation on breast feeding.

Laura M Lamberti et al. study on breastfeeding and the risk for

diarrhea morbidity and mortality showed excess risk of diarrhea in non-

exclusively breast fed 0-5 months aged infants; relative risk of diarrheal

incidence was 1.26, 1.68, and 2.65 in predominant, partial, and non-

breastfed group children respectively. Similarly, the estimated relative

risk of incident diarrhea was elevated when comparing non-breastfed to

breastfed 6-11 months aged infants.

We have observed the relationship of diarrheal incidence with

other demographic parameters also. But residence, water supply,

sanitation and parent's educational level had no significant influence on

incidence and frequency of diarrhea.

Summary
An observational cross sectional study was carried out in the Department

of Pediatrics, Burdwan medical college and hospital, Burdwan from 1st

september 2018 to 30 th April 2020. Total 200 children , aged 1 to 24

months having diarrhea attending in and out patient department was

enrolled in this study. Data was collected by face to face interview using

a structured close ended questionnaire information regarding

demographic data; containing detailed feeding history and information

of diarrhea. Study was conducted after the approval of the institutional

ethics committee and by getting due consent from the care givers.

The exclusive breast feeding children has lower incidence of frequent

attacks of diarrhea (25%) when compared to exclusive formula feeding

(71.4%) and both formula and breast feeding (59.5%) children .

Only 20 % of children among exclusively breast fed had their first attack

of diarrhea with in first 6 months of life when compared to 80 % (65%

+15%) of children with non exclusive breast feeding (breast feed

plus formula feed and exclusive formula feeding)

Based on this study it is clear that children who is exclusively breast

feeding have lower incidence of diarrhea when compared to children

with non exclusive breast feeding ( breast feed plus formula feed and

exclusive formula feed).

Conclusion
Breast feeding reduces

1) incidence of diarrhea,

2) prevents frequent attack of diarrhea and

3) prevents early occurrence of diarrhea in under two children.

Residence, water supply, sanitation and parent's educational status may

not have significant influence on incidence of diarrhea.

RECOMMENDATION :

1) Exclusive breast feeding for first six months of life and continuation

of breast feeding for two years or beyond

2) Exclusive formula feeding should be avoided in children less than 6

months.
Bibliography
A STUDY ON THE MAGNITUDE OF DIARRHEA IN BREAST-
FED VERSUS FORMULA-FED BABY.

QUESTIONAIRE

IDENTIFICATION NUMBER:
IDENTIFICATION DATA:
DATE OF BIRTH:
BIRTH WEIGHT:
WEIGHT (K.G.) :
HEIGHT (CM) :
AGE:
AGE GROUP : □ 1-6 MONTH
□ 7-12 MONTH
□ 13-18 MONTH
□ 19-24 MONTH
SEX: MALE/FEMALE
RELIGION: HINDU/MUSLIM/OTHER(please specify)
…………………………..
TYPE OF FEEDING : □ EXCLUSIVE BREAST FEED
□ EXCLUSIVE FORMULA FEED
□ BREAST FEED + FORMULA FEED
FIRST OCCURRENCE OF DIARRHEA : □ 1- 6 MONTH.
□ 7- 12 MONTH.
□ 13 – 24 MONTH.

NUMBER OF DIAARHEAL ATTACK : □ 1ST ATTACK .

□ 2ND ATTACK .

□ 3RD ATTACK .

□ 4TH ATTACK OR MORE .

FORMULA FEEDING UTENSILS : □ BOTTLE .

□ CUP AND SPOON .

MOTHERS EDUCATION : □ ILLITERATE.

□ NON FORMAL LITERATE.

□ PRIMARY.

□ MIDDLE

□ HIGH/SECONDARY.

□ POST HIGH/HIGHER SECONDARY.

□ COLLEGE LEVEL

□ GRADUATE
FATHERS EDUCATION : □ ILLITERATE.

□ NON FORMAL LITERATE.

□ PRIMARY.

□ MIDDLE

□ HIGH/SECONDARY.

□ POST HIGH/HIGHER SECONDARY.

□ COLLEGE LEVEL

□ GRADUATE.

MOTHERS OCCUPATION : □ SKILLED

□ SEMI SKILLED

□ UNSKILLED.

□ UNEMPLOYED

□ PROFESSIONAL

FATHERS OCCUPATION : □ SKILLED

□ SEMI SKILLED

□ UNSKILLED.

□ UNEMPLOYED
 □ PROFESSIONAL

WATER SUPPLY : □ TUBE WELL .

□ TAP WATER .

RESIDENCE : □ URBAN .

□ URBAN-SLUM .

□ RURAL .

SANITATION : □ PUCCA.

□ WATERSEAL.

□ KUTCHA.

□ OPEN AIR.

…………………
…………………………………………………….

SIGNATURE OF THE INTERVIEWER WITH DATE

ANNEXURE

KEYS TO MASTER CHART

1 ) SEX

MALE -1

FEMALE -2

2 ) AGE GROUP

1 – 6 MONTHS -1

7 – 12 MONTHS -2

13 – 18 MONTHS -3

19 – 24 MONTHS -4

3 ) TYPE OF FEEDING

EXCLUSIVE BREAST FEEDING -1

BREAST FEEDING PLUS FORMULA FEEDING -2

EXCLUSIVE FORMULA FEEDING -3

4 ) FIRST OCCURRENCE OF DIARRHEA :
1- 6 MONTH -1
7- 12 MONTH -2
13- 24 MONTH -3

5 ) NUMBER OF DIAARHEAL ATTACK :

1ST ATTACK -1

2ND ATTACK OR MORE -2

6 ) FORMULA FEEDING UTENSILS :

BOTTLE -1

CUP AND SPOON -2

7 ) MOTHERS EDUCATION :

ILLITERATE -1

NON FORMAL LITERATE -2

PRIMARY -3

MIDDLE -4

HIGH/SECONDARY -5

POST HIGH/HIGHER SECONDARY -6

 COLLEGE LEVEL -7

GRADUATE -8

8 ) FATHERS EDUCATION :

ILLITERATE -1

NON FORMAL LITERATE -2

PRIMARY -3

MIDDLE -4

HIGH/SECONDARY -5

POST HIGH/HIGHER SECONDARY -6

COLLEGE LEVEL -7

GRADUATE -8

9 ) MOTHERS OCCUPATION :

SKILLED -1

SEMI SKILLED -2

UNSKILLED -3

UNEMPLOYED -4
 PROFESSIONAL -5

10 ) FATHERS OCCUPATION :

SKILLED -1

SEMI SKILLED -2

UNSKILLED -3

UNEMPLOYED -4

PROFESSIONAL -5

11 ) WATER SUPPLY :

TUBE WELL -1

TAP WATER -2

12 ) RESIDENCE :

URBAN -1

RURAL -2

URBAN-SLUM -3

13 ) SANITATION :

PUCCA -1
WATERSEAL -2

KUTCHA -3

OPEN AIR -4
Master chart
 MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
1 2 2 1 4 5 1 6
2 1 1 2 4 1 3 1
3 2 2 1 1 5 2 7
4 3 2 1 4 3 1 4
5 2 1 1 3 3 2 3
6 3 1 1 4 4 3 5
7 4 1 1 1 6 1 7
8 1 1 2 4 1 3 1
9 2 2 1 2 8 5 8
10 2 1 2 4 7 1 7
11 3 2 2 3 5 2 6
12 2 1 2 4 2 1 5
13 3 1 2 4 3 2 4
14 2 1 3 4 3 3 3
15 1 2 1 1 6 1 7
16 4 1 1 4 4 1 5
17 3 1 1 3 2 3 1
18 2 2 2 4 4 1 5
19 3 1 1 1 3 2 4
20 1 1 2 4 5 1 7
21 2 1 2 4 4 2 4
22 3 2 1 3 3 3 3
23 1 1 2 4 5 1 6
24 2 1 1 4 5 2 7
25 2 2 2 1 4 1 5
26 3 1 1 4 2 3 1
27 1 1 3 2 4 1 5
28 2 1 1 4 6 2 7
29 4 2 3 1 3 2 4
30 2 1 2 3 1 3 1
15 1 2 1 1 6 1 7
16 4 1 1 4 4 1 5
17 3 1 1 3 2 3 1
18 2 2 2 4 4 1 5
19 3 1 1 1 3 2 4
20 1 1 2 4 5 1 7
21 2 1 2 4 4 2 4
22 3 2 1 3 3 3 3
23 1 1 2 4 5 1 6
24 2 1 1 4 5 2 7
25 2 2 2 1 4 1 5
26 3 1 1 4 2 3 1
27 1 1 3 2 4 1 5
28 2 1 1 4 6 2 7
4 2 3 1 3 2 4
MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
31 3 1 1 4 4 1 5
32 2 2 2 4 6 1 7
33 3 1 1 3 3 3 3
34 3 1 1 4 4 1 5
35 1 2 3 2 5 2 6
36 2 1 1 1 5 1 5
37 2 2 1 4 1 3 1
38 2 1 1 4 7 1 5
39 3 1 1 1 7 2 7
40 1 2 2 3 2 3 1
41 2 2 2 4 3 2 4
42 1 1 1 4 2 3 1
43 1 1 2 4 5 2 7
44 3 2 2 1 5 1 5
45 4 1 1 4 3 3 3
45 4 1 1 4 3 3 3
46 2 2 1 3 5 1 6
47 3 2 3 4 5 1 7
48 3 1 2 4 4 2 5
49 2 2 1 3 5 1 5
50 2 1 2 4 3 2 3
51 2 1 2 1 3 1 4
52 2 1 1 4 5 3 1
53 1 1 2 3 5 1 5
54 2 2 1 4 6 2 7
55 3 1 2 4 1 3 1
56 2 1 1 4 5 1 5
57 3 2 1 4 5 2 6
58 3 1 1 3 2 3 1
59 4 1 1 4 3 2 3
MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
61 2 1 2 3 6 2 7
62 1 1 3 4 5 2 6
63 3 2 1 1 3 3 3
64 4 1 2 4 5 1 7
65 2 1 1 3 4 1 5
66 3 1 3 1 5 2 6
67 2 1 2 4 3 2 4
68 2 1 2 3 1 3 2
69 2 1 2 2 5 1 5
70 1 2 3 4 1 3 1
71 3 1 1 4 5 2 5
72 2 1 1 3 5 1 7
73 3 1 2 4 6 1 7
74 2 2 1 1 4 1 5
75 2 1 1 4 4 1 5
75 2 1 1 4 4 1 5
76 1 1 2 4 1 3 1
77 2 2 1 4 3 2 3
78 3 1 1 3 5 2 7
79 3 1 1 3 1 3 1
80 1 2 2 1 3 2 4
81 1 1 1 4 4 3 5
82 3 2 1 3 5 1 7
83 2 1 3 3 3 2 3
84 4 1 2 4 5 1 6
85 2 2 1 1 1 3 1
86 3 1 1 4 5 1 7
87 3 1 2 3 4 2 4
88 2 2 2 2 5 2 5
89 1 1 2 4 3 3 3
MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
91 3 2 1 4 6 1 7
92 3 1 1 3 4 1 5
93 2 1 3 4 5 3 1
94 1 2 1 4 5 1 6
95 4 1 1 3 4 2 5
96 2 1 1 1 3 3 3
97 3 1 1 4 1 3 1
98 3 1 2 2 5 1 5
99 4 1 1 4 6 1 7
100 1 2 2 3 3 2 4
101 3 2 1 3 2 3 2
102 2 1 2 4 5 2 6
103 1 1 2 1 4 1 5
104 2 2 3 3 3 2 4
105 2 1 2 4 1 3 1
 MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
121 1 2 1 3 5 2 5
122 3 1 2 4 5 3 5
123 4 2 1 1 3 1 4
124 2 1 2 3 6 2 7
125 2 1 2 4 5 1 6
126 3 1 2 1 3 3 3
127 3 1 1 4 5 2 5
128 2 2 1 3 1 3 1
129 2 1 1 2 4 2 5
130 1 1 3 3 5 1 7
131 2 2 1 1 3 1 4
132 3 1 2 4 5 2 5
133 2 1 1 4 5 1 6
134 2 1 2 4 4 1 5
135 2 1 3 2 5 1 5
136 3 2 2 3 1 3 1
137 1 1 2 4 5 2 5
138 3 1 2 3 6 1 7
139 4 1 1 4 3 2 4
140 1 2 2 1 5 3 5
141 3 2 1 3 4 2 5
142 1 1 2 3 5 3 7
143 2 1 3 1 4 1 5
144 3 1 1 4 3 2 4
145 4 1 1 4 6 2 7
146 2 2 2 1 3 3 3
147 3 1 1 3 4 1 5
148 1 1 1 4 5 1 5
149 2 1 2 4 1 3 1
150 2 1 1 3 5 2 5
135 2 1 3 2 5 1 5
136 3 2 2 3 1 3 1
137 1 1 2 4 5 2 5
138 3 1 2 3 6 1 7
139 4 1 1 4 3 2 4
140 1 2 2 1 5 3 5
141 3 2 1 3 4 2 5
142 1 1 2 3 5 3 7
143 2 1 3 1 4 1 5
144 3 1 1 4 3 2 4
145 4 1 1 4 6 2 7
146 2 2 2 1 3 3 3
147 3 1 1 3 4 1 5
148 1 1 1 4 5 1 5
149 2 1 2 4 1 3 1
MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
151 3 1 1 4 5 1 5
152 2 1 1 4 7 1 7
153 3 2 1 4 3 1 4
154 2 1 1 3 4 3 5
155 2 1 2 4 5 2 6
156 3 1 2 3 5 3 5
157 1 2 2 4 3 2 4
158 2 1 1 4 5 1 5
159 2 1 3 2 6 2 7
160 1 2 2 3 2 3 3
161 3 1 1 4 5 2 5
162 1 1 1 3 1 3 1
163 2 2 2 4 6 1 7
164 3 2 1 4 4 1 5
165 3 1 2 3 6 1 6
173 4 2 1 1 5 1 5
174 3 1 1 4 1 3 1
175 1 1 2 3 5 1 5
176 2 1 2 4 5 2 6
177 2 1 2 4 5 1 5
178 3 1 1 3 3 3 3
179 2 1 1 3 5 2 7
MOTHER'S MOTHER'S FATHER'S FATHER'S
S.NO AGE SEX FEEDING OCCUPATION EDUCATION OCCUPATION EDUCATION
181 3 2 1 3 3 2 3
182 1 1 2 4 4 3 5
183 2 1 2 3 5 1 7
184 4 2 3 4 5 2 6
185 2 2 1 2 4 2 5
186 3 1 3 4 1 3 1
187 3 1 1 3 6 2 5
188 2 1 3 4 2 3 2
189 3 2 1 4 3 1 4
190 1 1 2 1 6 1 7
191 2 1 2 3 4 2 5
192 2 1 1 4 5 3 5
193 3 1 1 4 3 2 3
 AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
1 2 1 1 2 1 -
2 1 1 2 1 1 1
3 2 1 1 2 1 -
4 1 2 1 3 1 -
5 2 1 1 1 1 -
6 2 3 2 2 1 -
7 2 1 1 1 1 -
8 2 3 1 1 1 1
9 1 1 1 2 1 -
10 1 1 1 2 1 1
11 2 3 1 2 2 2
12 3 2 2 2 2 1
13 2 1 1 3 2 2
14 1 1 2 1 2 2
15 2 1 1 1 1 -
16 2 3 1 3 1 -
17 2 4 1 2 2 -
18 2 1 1 2 2 1
19 2 1 1 3 1 -
20 2 3 1 1 2 1
21 2 3 1 1 1 1
22 1 1 1 2 1 -
23 2 2 1 1 1 1
24 1 1 1 2 1 -
25 2 1 2 2 2 1
26 1 2 1 3 1 -
27 2 1 1 1 2 1
28 1 1 1 1 1 -
29 2 1 1 3 2 1
30 3 3 2 1 2 1
15 2 1 1 1 1 -
16 2 3 1 3 1 -
17 2 4 1 2 2 -
18 2 1 1 2 2 1
19 2 1 1 3 1 -
20 2 3 1 1 2 1
21 2 3 1 1 1 1
22 1 1 1 2 1 -
23 2 2 1 1 1 1
24 1 1 1 2 1 -
25 2 1 2 2 2 1
26 1 2 1 3 1 -
27 2 1 1 1 2 1
28 1 1 1 1 1 -
29 2 1 1 3 2 1
AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
31 2 1 1 2 1 -
32 2 3 1 2 2 1
33 2 4 1 3 1 -
34 1 1 2 3 2 -
35 2 1 1 1 1 1
36 2 1 1 2 1 -
37 2 3 1 2 1 -
38 1 1 1 2 1 -
39 2 3 1 3 2 -
40 1 1 1 1 2 1
41 1 1 1 1 1 2
42 3 3 2 1 1 -
43 2 1 1 1 1 1
44 2 1 1 2 2 1
45 1 1 1 3 2 -
45 1 1 1 3 2 -
46 1 1 1 2 1 -
47 2 3 1 1 2 1
48 2 1 1 2 1 1
49 2 3 1 1 1 -
50 1 1 2 2 2 1
51 1 1 1 1 1 2
52 2 1 1 1 1 -
53 1 1 1 1 2 1
54 2 3 1 2 1 -
55 2 1 1 2 1 2
56 3 2 2 1 1 -
57 2 2 1 3 1 -
58 2 3 1 2 2 -
59 1 1 1 3 2 -
AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
61 1 1 1 2 2 1
62 2 3 1 1 1 1
63 2 3 1 2 1 -
64 2 2 1 3 2 1
65 1 1 1 1 1 -
66 2 1 1 2 2 1
67 2 4 2 2 1 1
68 2 1 1 2 2 2
69 2 1 1 1 2 1
70 1 1 1 1 1 1
71 2 3 1 1 1 -
72 2 3 1 1 1 -
73 1 1 2 3 1 2
74 1 1 1 2 2 -
75 2 1 1 2 1 -
75 2 1 1 2 1 -
76 2 1 1 1 2 2
77 3 2 2 1 1 -
78 1 1 1 2 1 -
79 2 3 1 3 2 -
80 1 1 1 1 2 2
81 1 1 1 1 1 -
82 2 3 1 2 1 -
83 2 1 1 1 1 1
84 2 1 1 1 1 1
85 1 1 1 2 2 -
86 1 3 2 3 1 -
87 2 2 1 3 2 1
88 2 1 1 2 2 1
89 2 1 1 1 2 1
AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
91 2 1 1 2 1 -
92 2 1 1 2 1 -
93 2 3 1 2 2 1
94 1 1 1 1 1 -
95 3 3 2 2 2 -
96 2 1 1 2 1 -
97 1 1 1 2 1 -
98 2 1 1 1 2 1
99 2 2 1 3 1 -
100 2 3 1 1 1 1
101 1 1 1 2 1 -
102 2 3 1 1 1 1
103 2 3 1 1 1 1
104 1 1 1 2 2 1
105 1 1 2 1 2 1
105 1 1 2 1 2 1
106 1 2 1 3 1 -
107 2 1 1 3 2 -
108 1 1 1 1 1 1
109 1 1 1 1 2 1
110 2 3 2 3 1 -
111 1 1 1 1 2 2
112 1 1 1 2 1 -
113 1 1 1 2 2 -
114 2 2 1 3 1 -
115 1 1 1 2 1 1
116 2 3 1 2 2 1
117 2 1 1 1 2 1
118 1 1 1 2 2 -
119 1 1 1 2 1 -
AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
121 1 1 1 1 1 -
122 1 1 1 2 2 1
123 2 3 1 3 2 -
124 1 3 1 1 1 1
125 2 1 1 1 1 1
126 1 1 2 2 2 1
127 1 1 1 3 1 -
128 1 1 1 2 1 -
129 1 1 1 2 1 -
130 1 1 1 1 2 2
131 2 3 1 2 1 -
132 2 1 1 2 1 2
133 1 1 1 2 1 -
134 1 1 2 1 1 1
135 2 2 1 1 2 1
135 2 2 1 1 2 1
136 2 3 1 2 2 2
137 2 3 1 1 2 1
138 1 1 1 1 1 1
139 1 1 1 3 2 -
140 2 2 1 1 1 2
141 1 1 1 2 2 -
142 2 1 1 1 2 1
143 2 3 1 1 2 1
144 1 3 2 3 1 -
145 2 2 1 2 1 -
146 1 1 1 2 2 1
147 2 1 1 3 1 -
148 1 1 1 1 2 -
149 1 1 1 1 2 2
AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
151 1 1 1 2 1 -
152 2 3 1 2 1 -
153 2 1 1 3 1 -
154 1 1 2 2 1 -
155 1 1 1 1 1 1
156 2 3 1 2 2 1
157 1 1 1 1 2 1
158 2 3 1 2 1 -
159 1 1 1 2 1 1
160 1 1 1 1 2 1
161 2 1 1 2 1 -
162 3 2 2 1 2 -
163 1 1 1 1 2 1
164 2 3 1 2 1 -
165 2 1 1 2 1 1
172 2 3 1 2 1 1
173 1 1 1 3 1 -
174 1 1 2 3 2 -
175 2 3 1 1 2 2
176 2 1 1 2 2 1
177 2 3 1 1 2 2
178 1 1 1 3 1 -
179 1 1 1 2 2 -
AGE AT NO OF FEEDING
S.NO RESIDENCE SANITATION WATER SUPPLY ONSET ATTACKS UTENSIL
181 2 1 1 2 1 -
182 2 2 1 1 2 2
183 1 1 1 2 1 2
184 1 3 2 2 2 1
185 2 1 1 2 1 -
186 1 2 1 2 2 1
187 2 4 1 3 1 -
188 1 1 1 2 1 1
189 1 1 1 3 2 -
190 2 1 1 1 2 1
191 1 1 1 1 2 2
192 1 1 1 2 2 -