Target audience (uses): Field workers (to guide practice).

Three healthy breastfed generations in an Indonesian village (WHO/J.Ling)

I have experience of both methods and am convinced that cup and saucer regimens are better. The possibility of inhalation pneumonia in the recovering severely mal-nourished child has concerned me for years. There is no information in the literature on lung function or aspiration pneumonia in the severely malnourished child at any stage of recovery. Nevertheless, examination shows that a very high proportion have stigmata of chronic chest disease, almost certainly due to repeated bouts of pneumonia, that could easily be precipitated by inhalation. There is a need for pulmonary physiological studies (lung-function tests) in children with severe malnutrition - if any one is interested in such a study please get in touch with me.

The practice that we followed since 1956, in Jamaica, has been to use a cup and saucer, without a spoon, for the liquid feeds; spoons and bowls were used for solid food later in recovery. Choking and inhalation were more common in later recovery when solid food was given by spoon than when milk was given by cup only.

There is a definite technique to feeding a malnourished child properly. It is not taught to the people who either train the local staff or to the mothers. The critical thing is to have the child physically on the lap of the person feeding the child, held securely in a "cuddle" against the chest, facing forward in an upright posture, with the mother's left arm encircling the child and holding the saucer under the chin. The right hand holds the cup for the child to drink. Any "dribbles" are collected in the saucer and returned to the cup. The most important thing is to teach the mothers how to hold their children during feeding and to have someone who is properly trained watching the children as they are fed.

With a spoon and cup there are several problems that I have repeatedly witnessed.

1. The feeding is very slow. This is a major difficulty because one of the main functions of the attendants is to watch the children during feeding. Such surveillance is critical to ensure that the child gets the food and to assess the child's appetite. Rates of recovery improve with adequate surveillance as less is taken by the mother, none is shared with other siblings and more can be offered where the patient is hungry making feeding "to appetite" a reality.

2. There is a lot of spilt food. A lot of the milk "dribbles" down the front of the child and is lost. Investigation of poor weight gain, despite high calculated intakes, shows that up to a third of the meal can actually be spilt with improper feeding. Test weighings with the cup only method (weigh both the cup and the child before and after the feed), where a saucer below the chin catches the dribbles, gives a measured loss of just under 10%. With a spoon or with self-feeding the losses are much higher.

3. The child is often left to take the food him/herself. This is perhaps the most damaging feature of the spoon and cup. The child is not being cuddled and held during feeding and actively encouraged by the mother. Feeding is one of the most important times to show love and to psycho-socially stimulate the child - to talk to the child and have bodily contact.

4. Damage may occur during force feeding. If the child is reluctant to eat then the mother or aide frequently attempt to force the child's mouth open by pinching the cheeks, holding the nose and/or forcing the spoon between the lips. A spoon causes much more trauma to a child's mouth than a cup. I have seen children with stomatitis receive quite deep cuts in their mouths from spoons.

5. It is during force feeding that inhalation is most likely to occur. As force feeding is much easier with a spoon than a cup, it is my experience that inhalation pneumonia is more common following feeding with a spoon (both food and medicines) than with a cup only.

Going round Therapeutic Feeding Centres in West Africa, where cups and spoons were being used, I demonstrated to the local staff and mothers how to feed their children with a cup and saucer. They have all since reported back that they find this method to be better, problems that they had, have resolved and weight gains have improved.

I would like to hear from those who have a different practical experience from mine; such practical aspects of feeding the child are very important but have never been satisfactorily addressed by scientific investigation.

For further discussion on this subject contact Prof. Michael H.N.Golden, Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, AB25 2ZD, Scotland, (UK). E-mail: m.golden@abdn.ac.uk

(See also Annex VIII)