S Leung

1. Breast Feeding

Hong Kong has recorded the lowest ever breast feeding rate of 5% in 1978. Since then, the rate steadily increased as a result of the continuing demand from the public and the joint effort of the medical and nursing staffs. With the establishment of the Baby Friendly Hospital Initiative Hong Kong Association in 1992 the rate of increase was even more rapid.

The Baby Friendly Hospital Initiative, Hong Kong Association (BFHIFIKA) was formed with the support of UNICEF, Hong Kong in response to the global action of UNICEF Baby Friendly Hospital Initiative. It consists of doctors (Paediatricians, Obstetricians), nurses (lactation consultants, midwives), lawyers, and teachers, all serving towards the common goal to protect, promote and support breast feeding. Training skilled nursing staffs had been a major role of the Association. Up till now, 50 nurses passed the international examination for the lactation consultants. They helped to serve the hospitals, maternal and child health clinics and community hotlines. The ever breast feeding rate has risen from 19% in 1992 to 47.4% in 1998.¹ Although there are at least two mothers group to support breast feeding (an international one, La Leche League and a local one, Hong Kong Breastfeeding Mothers Support Group), the drop out rate of breast feeding was high. Preliminary data showed that only 32% of those who initiated breast feeding continued to breastfeed at 2 months.

None of the hospitals comply to all the ten steps of Baby Friendliness. The main problems lies in the acceptance of free supply of infant formula from the milk companies. Routine or supplemental bottles of artificial milk were offered too readily to babies. All public hospitals practice rooming in while most private hospitals do not. There is a general belief that paying more money to deliver babies in private hospitals should have in return a quiet sleep and rest in hospitals while nurses should help in baby care including feeding babies. Moreover, the international code of marketing infant formula was not generally known to the medical and nursing staffs and milk companies tend to violate the marketing code. At the moment, both the BFHIHKA and the Hong Kong Paediatric Society are reacting to such violations by letters of warning. It is encouraging that a few hospitals have expressed their wish to fulfill the ten steps to become baby friendly.

Some may think that mothers working could be the main reason for the low breast feeding rate. However, studies have shown that only forty percent of Hong Kong mothers were working when their babies were four months old. It is more likely though that a working mother or an educated mother would choose to breast feed. These working mothers had ten weeks of maternity leave only. Milk collection during office hours for working mothers is a real problem. There was generally no public facilities such as nursing rooms in the shopping enters or working place. Undoubtedly, a lot more education to the public and policy workers is required.

2. Bottle feeding and weaning

There are over thirty brands of infant formula available in Hong Kong. They include the early starting formula, special formula and the so called follow on formula. Many mothers were led to belief that once a baby was on starting formula, he or she should be shifted to the follow on formula at six months of age. The latter consists of protein content double that of starting formula or human milk. The misconception was that the 'low' protein content of either the starting formula or human milk is inadequate for infants' need after six months of age. Very often, infant formula was given to infants even beyond two years of age. And, unlike the traditional Chinese Hong Kong children continued to drink milk through their childhood.²

The high protein content of the follow on formula together with the abundance of meat in the rice-based weaning food resulted in the high protein intake: four times the recommended daily safe level of protein requirement.³ The high content of animal protein (including milk protein) and animal fat may have contributed to the rising incidence of allergic diseases, obesity and diabetes mellitus of children in Hong Kong.

Iron deficiency and rickets which are common problems of weaning infants in many parts of the world are not commonly seen in Hong Kong.^4-5 Nor there has been reports on calcium deficiency. It was amazing to find that the true calcium absorption of Chinese children as measured by the double labelled calcium isotope was 60%, double that of the Caucasian population.⁶ Such findings challenge the applicability of the recommended calcium requirement derived from the habitually high calcium intake populations. A long term adaptation could have occurred among the Asian populations whose diet is traditionally free of milk or dairy products.

3. Childhood obesity

The detection of childhood obesity requires growth surveys and standards for diagnosing obesity. The first territory wide growth survey in Hong Kong was performed in the sixties⁷ when obesity was not described as a problem. Distribution of the weight percentile curves was not skewed. The second territory wide growth survey was performed in the nineties, showing a very much skewed weight distribution in the childhood and adolescent age. Weight for height references were established as a measurement of childhood obesity. Between 6-18 years, 10-13% boys and girls had weight above 120% median weight for height of the same sex.⁸ There were more obese boys than obese girls. Obesity is associated with lower high density lipoprotein cholesterol⁹ and impaired glucose tolerance.¹⁰ Emergence of childhood obesity pose a major nutritional problem in Hong Kong, similar to many other affluent Asian cities. Transitional health problems like diabetes mellitus, coronary heart disease are expected to be on the rise in the near future.

With the establishment of Student Health Service in 1996 by the Department of Health in Hong Kong, students were physically checked once a year. Surveillance of childhood obesity can easily be performed. Preliminary data showed an increase of prevalence of obesity. Using the same criteria within 3 years, the prevalence of obesity in children of 7 years old increased 2.8% in boys (7.6% in 1993 and 10.4% in 1996) and 1.1% in girls (7.8% in 1993 to 8.9% in 1996). Undoubtedly more education on healthy eating and healthy life style is required.

References

1. Annual Report 1998. Baby Friendly Hospital Initiative Hong Kong Association, Hong Kong.

2. Lee WTK, Leung SSF, Ng MY, Wong SF, Xu YC, Zeng WP, Lau J. Bone mineral content of two populations of Chinese children with different calcium intakes. Bone & Mineral, 1993;23:195-206.

3. Leung SSF, Lui S. Nutritive value of Hong Kong Chinese weaning diet. Nutrition Research, 1990;10:707-15.

4. Leung SSF, Davies DP, Lui S, Lo L, Yuen P, Swaminathan R. Iron deficiency is uncommon in Hong Kong infants at 18 months. J Tropical Paediatr, 1998;34:100-3.

5. Leung SSF, Lui S, Swaminathan R. Vitamin D status of Hong Kong Chinese Infants. Acta Paed Scan, 1989;78:303-6.

6. Lee WTK, Leung SSF, Fairweather-tait SJ, et al. True fractional calcium absorption in Chinese children measured with stable isotopes (42 Ca and 44 Ca), Br J Nutri, 1994;72:883-7.

7. Cheng KSF, Lee MMC, Low WD. Standards of the height and weight of Southern Chinese children. Far East Medical Journal, 1965;1:101-9.

8. Leung SSF, Tse LY, Leung NK. Growth and Nutrition in Hong Kong children. Singapore Paediatric Journal, 1996;38(2):61-66.

9. Leung SSF, Chan YL, Lam CWK, Peng XH, Woo KS, Metreweli C. Body fatness and serum lipids of 11-year-old Chinese children. Acta Paediatr, 1998;87:363-7.

10.Wong GWK, Leung SSF. Impaired Glucose Tolerance in Obese Chinese Children in Hong Kong. Hong Kong Journal of Paediatrics, 1993;109-12.