Health Inequalities |
Relation between the socioeconomic status of the family and primary allergy prevention in infant feeding in Hajdú-Bihar County, Hungary
Gabriella Páll1, Margit Szövetes2, Hajnalka Márton3, Istvánné Molnár4, Zoltán Vokó5, Erzsébet Szakos6, Sándor Sipka6, István Ilyés3, Gyula Szegedi6,7 and Gabriella Pásti4
1 National Institute of Child Health, Hungary
2 Primary Health Care Service of Debrecen, Hungary
3 Department of Family Medicine, Medical and Health Science Centre, University of Debrecen, Hungary
4 National Public Health Service, Hajdú-Bihar County, Hungary
5 School of Public Health, Medical and Health Science Centre, University of Debrecen, Hungary
6 3rd Department of Internal Medicine, Medical and Health Science Centre, University of Debrecen, Hungary
7 Hungarian Academy of Sciences, University of Debrecen, Research Team of Autoimmune Diseases
Correspondence: Dr Gabriella Páll, Batsányi J. u. 1, Gödöllö, H-2100 Hungary, tel: +36 365 1540 131, fax: +36 1 209 3337, e-mail: gabipall{at}ogyei.hu
, accepted October 26, 2004
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Abstract |
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Background: The relationship between socioeconomic status and preventive care is an important issue in public health practice in Hungary. Our aim was to investigate the association between the socioeconomic status and the present practice of primary allergy prevention in infant feeding in Hajdú-Bihar County, Hungary. Methods: A questionnaire-based cross-sectional survey was performed among 3076 infants aged 0–6 months. We studied how socioeconomic status, type of settlement, allergic background of the family and skin symptoms indicative for allergy were related to primary allergy prevention in infant feeding. Prevalence odds ratios (ORs) were calculated by multiple logistic regression. Results: Independent determinants of breast feeding were age [OR corresponding to one month change 0.74; 95% confidence interval (CI) 0.70–0.77], the female gender (OR 1.24; 95% CI 1.06–1.46), the socioeconomic status of the family (OR comparing the worst with the best category 0.63; 95% CI 0.43–0.93), and birth weight (OR comparing <1500 g to >2500 g category 0.17; 95% CI 0.07–0.41). Among supplementary nutrient users independent determinants of the use of hydrolysed infant formulae were the socioeconomic status (OR comparing the worst with the best category 0.06; 95% CI 0.01–0.27), the type of settlement (OR comparing village with town 0.48; 95% CI 0.28–0.80), history of allergy in the family (OR 2.30; 95% CI 1.28–4.11), and skin symptoms indicative of allergy (OR 3.46; 95% CI 1.96–6.14). Conclusion: Socioeconomic status is related to the implementation of primary allergy prevention in infant feeding.
Keywords: infant nutrition, primary prevention, socio-economic factors
Increasing incidence of allergic diseases requires development of effective ways of prevention. Preventive measures in infant feeding are considered to be an important part of allergy prevention.1–4 There is some evidence that early exposure to allergenic proteins in an infant's diet, especially to cow's milk proteins, increases the risk of early food allergy and eczema,5,6 and may also play a role in the development of later respiratory tract allergies.7,8 Primary allergy prevention is strongly recommended for all infants at high risk of allergy. Infants having at least one first-degree relative with allergic disease (asthma, allergic rhinoconjuctivitis, eczema or food allergy) belong to the high-risk population. Since the risk of developing allergies in childhood is 5–10% in normal-risk groups, it may be useful to take some general preventive measures in the total population, too.
Exclusive breast feeding up to 5–6 months is highly recommended for both high-risk and normal-risk infants.9 In case of shortage or lack of breast milk replacement or supplementation is necessary. In the high-risk group, the use of partially or extensively hydrolysed infant formulae may reduce later allergies.10–14 These products are exposed to different procedures of hydrolysis in order to reduce allergenicity.15 There is no unified recommendation for the use of hydrolysed formulae in normal-risk subjects.
The form of infant feeding depends on not only the recommendations and willingness of health care providers, but also the socioeconomic status (SES) of the family. In some investigations the SES was found to be an independent determinant of exclusive breast feeding in the first months of life.16–20 However, there were no studies investigating the relationship between the SES of the family and use of hydrolysed infant formulae.
The aim of our study was to investigate the relationship between the SES of the family and the present practice of infant feeding. We investigated the determinants of exclusive breast feeding, and the determinants of use of hydrolysed formulae among supplement users.
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Methods |
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A questionnaire-based cross-sectional survey was performed among 3076 infants at the age of 0–6 months. All infants born in Hajdú-Bihar County, Hungary between 1 July 2000 and 31 December 2000 were involved in the study. Table 1 shows the major characteristics of the study population.
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The questionnaires were filled in by specially trained home visitor preventive nurses with the help of the mothers of the infants. Data were collected about the form of feeding, SES (table 2) and potential confounders [allergic medical history of parents and siblings, symptoms of the skin, the gastrointestinal and the respiratory tract, which could be indicative for allergy, common indoor allergens, passive smoking, type of settlement (village or town), qualification of the primary health care provider (paediatrician or general practitioner) and events of the perinatal period]. To classify children according to SES, seven different parameters were considered: settlement of living, house of living, quality of flat, marital status of mother, qualification of mother and father, and behaviour of the parents.
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In 2000, 6023 babies were born in Hajdú-Bihar County;21 therefore about 3010 infants were expected to be involved in the study. Due to the active support of the principle home visitor of the county all home visitors participated in this research and data on 3076 infants were collected. Home visitors did not report any refusal. Of every questionnaire that could be assessed, 151 (4.9%) were incomplete.
Families were grouped into four SES categories (table 2). Categorisation was based on the following rule: a score was given to each element of SES, and divided by the possible number of categories of the variable. This way a variable with a possible value from 0 to 1 was created. Larger values indicate worse SES. Then the values of the seven SES variables were added. Thus, an indicator with potential values from 0 to 7 was created to describe the SES of the family. This number was categorised into four groups: 1, very good SES (<10 percentile); 2, good SES (10–50 percentile); 3, bad SES (50–90 percentile); 4, very bad SES (>90 percentile).
Home visitors filled in the questionnaires using the exact name of the infant formulae, and it was classified by paediatricians on the basis of its protein content (normal cow's-milk based, partially or extensively hydrolysed, soy based). Exclusive breast feeding was considered when the infant did not get any formulae, or any kind of milk. Solid foods were not labelled in relation to exclusive breast feeding.
Infants were ranked into high-risk and non-high-risk groups on the basis of the allergic medical history of the family. The high-risk category was defined as at least one first-degree relative suffering from any allergic disease, diagnosed by a doctor (asthma, allergic rhinoconjuctivitis, eczema, or food allergy).
2 Test and multiple logistic regression were used for statistical analysis. Adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were reported to summarise the results. All statistical analyses were performed using Version 5.0 of the STATA software system (Stata Corporation, Texas, USA).
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Results |
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The SES was found to be an indicator of infant feeding in the crude analysis (figure 1). The breast feeding rate was the highest in the best SES category (exclusive breast feeding at the age of the interview in 69.8%), followed by the worst category (62.4%) (figure 1). Lower breast feeding rates were found in the middle categories.
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Age, gender, SES and birth weight were found to be independent determinants of breast feeding, according to the result of multiple logistic regression analysis (table 3). The rate of exclusive breast feeding decreased by about 30% monthly compared with the first month of life. Our results show that girls have an approximately 20% higher odds to be breast fed than boys. Infants in the lowest socioeconomic group had 40–50% lower odds to be exclusively breast fed than infants in the highest socioeconomic category. Babies with smaller birth weight had a notably smaller chance of being breast fed than babies with birth weight above 2500 g.
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The qualification of the primary health care provider and the type of settlement were not independent determinants of exclusive breast feeding.
Among participants not exclusively breast fed the rate of hydrolysed formulae within all types of formulae used was strongly determined by the SES of the family. While the rate of hydrolysed formulae in group 1 (very good SES) was approximately half of all formulae used for high-risk infants, it was just 28.6% in group 2, 17.7% in group 3, and 14.3% in group 4 (figure 2). Not only infants at high risk but also at normal risk were fed by hydrolysed formulae. In this group the same relationship was found with the SES.
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History of allergy in the family, skin symptoms indicating allergies, good SES and living in towns were independent determinants of the use of hydrolysed formulae (table 4).
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There was no significant relation between the age, gender, birth weight of the infant, the qualification of the primary health care provider and the use of hydrolysed infant formulae.
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Discussion |
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The long term results of early infant feeding habits and interventions are dubious and need further investigation. As a first step, in this study we aimed to give a description of the feeding pattern and its determinants with the focus on allergy prevention, as primary allergy prevention in infant feeding has a beneficial effect on the development of later allergies, especially food allergy.1,2 This study is a basis of a cohort study, which investigates the impact of the early feeding on the development of allergies.
Besides its well-known positive health and social effects, exclusive breast-feeding up to 5–6 months may play a role in food allergy prevention during the first years of life. If supplement is unavoidable the prescription of hydrolysed infant formulae is recommended for infants at high risk of allergy.22,23
A number of factors affect the principles above. First of all, a lot of efforts have been made to increase the rate of exclusive breast feeding over the last decade in Hungary, such as rooming-in neonatal units, education of primary care providers and preventive home visitors. Though breast feeding rates have risen, the target of exclusive breast feeding up to 6 months has been achieved only for about 50% of infants. Approximately half of the infants need supplementation or replacement of breast milk in their first 6 months. This phenomenon is unfortunately not unique, as very low breast feeding rates have been reported from different parts of the world.16–20
We identified a number of factors associated with breast feeding. One of these factors was the age of the infant. The younger the infant the higher the chance he had for exclusive breast feeding. Our results show that girls have a higher chance of exclusive breast feeding than boys. This finding is interesting, and possibly shows a variation in social behaviour. Some decades ago boys definitely had a better social background for growing up. The same result was found in a Swiss study,17 but investigators from Sweden did not find any difference between the genders in the breast feeding rate.24
The breast feeding rate among infants with low birth weight was smaller than those of normal birth weight. This is possibly explained by the clustering of prenatal problems. Respiratory distress of pre-term infants, perinatal infections, congenital disorders and the different therapeutic procedures all tend to reduce the possibility of breast feeding. Mothers of these infants also deal with more pressure, which is another factor against breast feeding. This observation has been reported from many European studies.17,18,25,26
The SES of the family had a significant effect on the rate of breast feeding. Our results indicate that breast feeding is the most common in the best SES category, followed by the worst SES group. The lowest rates could be found in the middle groups. Highly educated parents belong to the best SES group, where the emotional attitude and approach to breast feeding is the best. Among people in the worst SES group traditions and economic pressure may account for the relatively auspicious situation. In a Mexican study the same connection was demonstrated between the SES of the family and exclusive breast feeding.27 Furthermore, in a study where only the educational level of the mother was taken into consideration, the same association was found.25
When supplementation of breast milk was needed it was replaced with some kind of infant formula in the most cases, but after the age of 4 months the usage of native cow's milk also appeared. The continuous development of the industry makes it possible to fulfil special needs,15 such as the usage of hydrolysed formulae for high-risk infants for allergy. It is important to give clear landmarks for the specially produced infant formulae, and to follow these indications accurately. In Hungary, national guidelines in infant feeding suggest partially hydrolysed formulae for high-risk infants, and extensively hydrolysed formulae for those suffering from cow's milk allergy.23 The National Health Insurance Fund supports a half price for partially and extensively hydrolysed formulae for high-risk infants. After confirmation of food protein allergy this support is 90% for extensively hydrolysed formulae.
The use of hydrolysed formulae was determined by the positive medical history of allergies in the family. It was expected, as this is the indication of these products. Nevertheless, the OR of 2.3 may be considered very low, as this factor should have been the only determinant of the use of these formulae.
When supplementation or replacement of breast milk is needed, there is a great difference between prescriptions of hydrolysed formulae according to SES. The higher SES category a family belongs to, the grater chance the infant has to be fed by hydrolysed formulae in case of shortage or lack of breast milk. Price of these products and cultural factors may play a major role in this phenomenon. Hydrolysed formulae were given in both high-risk and normal-risk groups, and the SES of the family equally affected the use of it in both groups. There is no clear suggestion for the use of these products in the normal-risk group.
Skin symptoms indicating allergy, mostly atopic dermatitis was also an independent determinant of hydrolysed formulae. Prescribing partially hydrolysed formulae in atopic infants is recommended if food protein allergy does not exist, and for infants having cow's milk allergy only the use of extensively hydrolysed formulae is advisable. In this study we did not investigate whether food protein allergy was confirmed or not. It is also interesting to realise that gastrointestinal and respiratory symptoms were not found to be independent determinants of the use of hydrolysed formulae. As these symptoms are not specific for allergies, it is possible that in most cases allergy is not taken into consideration as a causative factor of the symptoms. The difference in use of hydrolysed formulae according to settlement of living shows a still existing difference in infant feeding between towns and villages.
Our results indicate that in order to prevent allergy it is important to provide all possible medical and social help to promote correct feeding of the infants in low SES families.
Key points
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