The Child Who Refuses the Spoon
Rekha is 16 months old. She weighs 7.4 kg and measures 74 cm. Her mother says she is 'still a baby' and breastfeeds her on demand, day and night, but gives no family food except a bottle of rice water and diluted cow's milk three or four times a day. Meals are a struggle: her mother holds her arms, pushes the spoon in, and the child cries and turns her head away, so the mother gives up and breastfeeds her instead. She has had three episodes of loose motions in the past four months and has not gained weight. She stands holding furniture and says two or three words. The family eats rice, dal, seasonal vegetables and occasionally egg or small fish; there is a tube well and a toilet in the compound.
1. Identify three feeding practices in this case that are wrong and explain the harm each causes.
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(i) Breastfeeding on demand day and night at 16 months with almost no family food. Breast milk is still valuable up to two years, but after six months it cannot supply enough energy, iron and zinc for growth. A breastfeed just before a meal also fills her stomach so she refuses food, and the mother then breastfeeds again - a closed loop. This is the main reason her weight, 7.4 kg at 16 months, is well below the expected 9–10 kg.
(ii) Bottle-feeding rice water and diluted cow's milk. Rice water is mostly water with very little energy or protein; diluted milk is diluted energy. Cow's milk is low in iron and in large amounts can irritate the gut and cause slight blood loss. A bottle is also hard to clean, and the teat and neck hold milk residue where bacteria multiply - consistent with three loose-motion episodes in four months.
(iii) Force-feeding. Holding her arms and pushing the spoon in makes eating a struggle and a negative experience. She learns to refuse, may gag or choke, and the mother reads refusal as 'not hungry' and breastfeeds - which completes the cycle.
2. Plan a day's food for Rekha using the family pot, with approximate amounts and frequency, and say how her mother should offer it to avoid the struggle.
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Aim for 3 meals and 2 snacks, about three-quarters to one katori at a time, thick enough to stay on the spoon, with a teaspoon of oil or ghee added to raise energy without adding bulk.
- Early morning: breastfeed.
- Breakfast: mashed rice or khichdi with dal and a little ghee.
- Mid-morning: half a mashed banana or boiled potato.
- Lunch: soft rice, dal, mashed seasonal vegetables, small fish with bones removed.
- Afternoon: breastfeed.
- Evening: suji halwa, or rice flakes with milk, or a mashed boiled egg.
- Night: khichdi with egg or dal; breastfeed at night.
How to offer it: sit at her level and use a small spoon; let her hold a spoon of her own and touch the food; offer small amounts and stop when she turns her head away; eat with her so she copies; do not feed when she is sleepy or just after a breastfeed. A refused food should be offered again on another day - many children need eight to ten offerings before accepting a new taste. Patience plus repetition is the technique; force is not.
3. Give two reasons why the bottle and the force-feeding style increase her risk of infection and poor growth, and state one hygiene advice.
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Bottle: the teat, ring and neck cannot be cleaned properly without a brush and boiling, so milk and rice water sit in the crevices and bacteria multiply between feeds. Every feed then delivers a dose of infection. Each loose-motion episode drains nutrients, reduces appetite and sets growth back, which is exactly the pattern seen here - three episodes and no weight gain.
Force-feeding: it makes her associate eating with struggle, so she eats less, not more. It also raises the risk of choking and of food being pushed out rather than swallowed, and it stops her learning to judge her own hunger and fullness.
Hygiene advice: wash hands with soap before preparing food and before feeding, and after cleaning her; use a cup and spoon instead of the bottle; boil the water used; wash and cover utensils; keep cooked food covered and give freshly cooked food. Alongside this, ensure her vaccines are up to date and take her for growth monitoring and for treatment of each diarrhoea episode.