Articles

Contamination of Teats Used by Illiterate and Educated

Nursing Mothers in Ile-Ife, Nigeria

Isaac A. Elegbe~ MSc, ASCP; Ebenezer 0. Ojofeitimi, PhD; Iyabode Elegbe, RN; Margaret 0. Akinola, MB, ChB

.We assessed bacterial contamina-tion of infant feeding teats among nursing

mothers and identified pathogenic orga-nisms that might be associated with theincidence of diarrhea. The incidence ofdiarrhea among the infants of illiteratemothers was fivefold that of infants ofeducated mothers. The vast majority ofthe illiterate mothers poorly sterilizedtheir infants' feeding utensils. The most

Iprevalent pathogenic organism isolatedfrom the teats was enteropathogenic,E"scherichia coli, followed by Staphylo-,i:OCCUS aureus. Unhygienic handling of11eeds is an important factor in infantileI:liarrhea.

(Am J Dis Child 1982;136:672-674)

tries has been well recognized by sev-eral authors.4-6 Nigeria, one of thelargest countries in Africa, recognizedthe threat when it listed gastroenteri-tis as the most important preventabledisease to be tackled! Many workershave discussed the risk ofbottle-feed-ing to the health and survival of theinfants.I,8.11 Bottle-feeding is quicklybecoming more popular in developingcountries, and bottle-fed babies in

For editorial commentsee p 667.

bottles and teats av1J.ilable, and whetherthey prepared their babies' feeds prior tofeeding time. The criteria for selection ofmothers were based on the following: (1)the child's age being under 1 year; (2)whether the mother was bottle-feeding herinfants; {3) and whether the mother was inpossession of a bottle at the time of inter-viewing for inspection.

The teats of every bottle inspected werecollected fo'r bacterial investigation fromthose nursing mothers who met all thecriteria. Demographic data on mothers'ages, I~vel of education, and socioeconomicbackground were also obtained. Womenwith educational backgrounds equivalentto high school or above, who were able tocomprehend the questionnaire without anyassistance, and who were from a middlesocioeconomic class were regarded as liter-ate. Those falling short of these criteriawere regarded as illiterate,

Collection of Specimens

The teats collected were those that themothers considered clean or ready to beused in feeding their babies. Each of theinspected teats was collected aseptically in5 mL of sterile nutrient broth in a 100-mLwidemouthed flask covered with a prester-ilized stopper. Each flask was shaken vig-orously and allowed to stand for at leastfive to ten minutes before subculturingonto various media.

Processing of Specimens

Broth samples containing each teat weresubcultured after five to ten minutes usinga precalibrated platinum wire loop thatdelivered 0.01 mL of the broth to inoculatethe entire surface of a 5% defibrinatedsheep blood agar (trypticase soy agarbase). MacConkey agar, Salmonella andShigella agar, mannitol salt agar, and phe-nyl ethyl alcohol agar supplemented with5% sheep RBCs were also inoculated with

these countries have death rates twoto three times greater than theircounterparts in developed countries.12One reason babies in developed coun-tries are less apt to be exposed tobacterial contamination is the wide-spread use of commercially preparedformula with disposable feeding bot-tles and teats. Babies in developingcountries are not as privileged.

Therefore, we undertook this studyto investigate bacterial contaminationby isolating and specifying the typesof colonizing bacteria in the te~tscollected from nursing mothers.

PATIENTS AND METHODS

Four hundred thirty-two nursing moth-ers who brought their infants to MoreHealth Center, Ile-Ife, Nigeria, for eitherminor ailments such as fever, cough, ordiarrhea, or regular clinical checkups androutine immunizations between November1980 and May 1981 were interviewed byquestionnaire and interview schedule. Themothers were asked about specific meth-ods of "sterilizing the feeding utensils, theduration of sterilization, the number of

I nfant formula per se does not pre-dispose children to infantile diar-

rhea; rather it is the method of prepa-ration, .nonavailability of potablewater, ignorance, and the unhygienicc:onditions of feeding utensils thatexpose many children to illness.'.2 Bot-tle-feeding aids in bacterial contami-nation particularly in developingc:ountries where methods of steriliza-1;ion of feeding utensils are far from

satisfactory. Consequently, feeding11tensils, especially bottles and teats,(:an playa part in the development ofdiarrhea diseases}

The formidable challenge posed bydiarrheal diseases in developing coun--

From the Departments of Morbid Anatomy,Medical Microbiology and Parasitology (Mr]~Iegbe), and Community Health and Nutrition(Drs Ojofeitimi and Akinola and Ms Elegbe),Faculty of Health Sciences, University of Ife,lie-Ife, Nigeria.

Reprint requests to Department of MorbidJ\natomy, Medical Microbiology and Parasitolo-gy, Faculty of Health Sciences, Ile~Ife, Nigeria(Dr Elegbe).

672 Am J Dis Child-",.Vol 136. Aug 1982 Infant Feeding Hygiene-E!egbe et a!

not presoak the teats for more than 15minutes, at which time the level ofbacterial contaminants is still high. Inall, 47.5% of teats sterilized by miltonwater had less than 10J bacteria colo-nies per milliliter, as compared with3.1% of teats sterilized by other meth-ods as outlined in Table 2.

(24.3% ) were serologically positive forenteropathogenic strains of E coli(EPEC) using the polyvalent antisera.The strains of monovalent E coli were055 :k29, 0128:k67, 0124:k72, 086:k61,and 044:k74. Other bacteria isolatesincluded 14 (13.6%) Staphylococcusaureus, seven (6.8% ) Klebsiella pneu-moniae, two (1.9% ) Staphylococcusepidermidis, and seven (6.8% ) Proteusmirabilis. The distribution of the iso-lates and the method of sterilizing theteats are shown in Table 3. No bacte-ria were recovered from the controlteats (those soa~ed in milton waterfor at least 90 l:I:linutes). Table 2 showsthat some of the teats from educatedmothers were contaminated.

A gr~ater percentage of pathogensrecovered were from teats that werewashed with detergents and rerinsedwith water, but that were neithersoaked in milton water for at least 90minutes nor soaked at all. The illiter-ate mothers possessed the highernumber of contaminated teats, espe-cially those mothers who washed theteats ( without any form of steriliza-tion: Those who used milton water did

COMMENT

That the incidence of diarrheal dis-ease among the infants of illiteratemothers was almost five times that ofthe educated mothers should not besurprising. This becomes even'moreunderstandable when one comparesthe data in Table 1 with the number ofteats and bottles used by mothers infeeding their infants. The vast major-ity of the illiterate mothers had onlytwo bottles and two teats to feed theirinfants. Thus, opportunity for thor-ough washings and sterilization of theutensils to minimize bacterial con-tamination was greatly reduced.

Although we suggest that the highfrequency of diarrhea among theinfants of illiterate mothers resultedfrom their method of sterilizing the

broth samples containing the teats using a4-mm platinum wire loop. After t~e inocu-lation, all plates were aerobically incU-bated at 37 °C for 24 hours.

All bacteria recovered in excess of 10'colonies per milliliter were biochemicallyand serologically identified using proce-dures outlined previously.'3.14

As controls, 25 teats washed with deter-gents and thoroughly rinsed with waterbefore soaking in milton water (1% sodiumhypochlorite in water) for at least 90minutes were cultured using the aforemen-tioned technique.

RESULTS

Of the 432 mothers contacted dur-ing the period of the study, only 205met all the criteria stipulated. Theages of the mothers ranged from 20 to36 years. Fifty-six percent of themothers were illiterate and 44% wereeducated. Seventy-one (78%) of theliterate mothers used at least three tofour bottles and teats to feed theirinfants, whereas the vast majority ofthe uneducated mothers used only oneand at most tWo bottles and teats tofeed their infants. The methods ofsterilizing feeding utensils are shownin Table 1. Table 2 ShoWS the relation-ship of' bacterial contamination ofteats to the educational backgroundand methods of sterilization by nurs-ingmothers. A total of 82 (80% ) of the103 teats were grossly contaminatedby bacterial pathogens, which wererecovered from the teats for biochem-ical and serologic identifications. Inthree cases (2.9% ) Salmonella andShigella species were isolated.

Of the 49 species (48% ) that showedpure growth of organisms with themorphologic and biochemical charac-teristics 01' Escherichia coli,15.16 26

673Infant Feeding Hygiene-Elegbe et alAr, Dis Child-Vol 136, Aug 1982

Table 3.-Distribution of Isolates per Method of Sterilization

No. (%) of Isolates

Washing With

DetergentsandSoaking

in Milton Water

Washing WithDetergents and

Soaking inSalt Water

Washing With

Detergents

OnlyRinsing With

Water Only TotalSalmonella fyphi 0 (0.0) I 0 (0.0) 2 (2.4) 2 (2.4)0 (0.0)-

i (1.2) ,0 (0.0)

Washing With

Detergentsand Soakingin Hot Water

0 (0.0)Salmonella paratyphi 0 (0.0) .0 (0.0) 0 (0.0) 0 (0.0) 1 (1.2)

Enteropathogenic E coli 4 (4.9) 5 (6:~)~~ (~~~~) ~ ~~~~~ ~ ~~:~~ ~" !~D.II

,.- ~.S'taphylococcus aureus 3 (3.7) 4 (4A} , , 'i .

~

2 (2.4) I (1.2)26 (31.7)

~2 (2.4)

:.S'taphylococcus epidermidis

-Klebsielfa pneumoniae

Proteus mirabilis-

Total

containing hypochlorite has beenemphasized},8,11,16 We have shown thatprolonged storage in milto.n waterreduces contamination of infectiousbacteria in our country, where safewater supplies are not available inmost cities and villages.

The implication that the bottle-fedbabies whose teats were grossly con-taminated by bacteria are at high riskof gastroenteritis is supported byreports by other researchers.1,9

There is an urgent need to educatethe illiterate mothers in their localdialects on the reasons for ensuringhygienic possession of feeding uten-sils, and such an education programshould also include home visits toobserve both feeding utensils andhome environment. Above all, thesupreme qualities of breast milk withits bacteriostatic, amenorrheic, im-munol.ogic, nutritional, and economicadvantages should be constantlyemphasized to the mothers.

rhea, dysentery, and vomiting withinthe two to four weeks before thestudy. The ratio of reported cases ofdiarrhea among illiterate mothers veducated mot~ers was 5:1.

The low count of bacteria in theteats from the edu<;ated mothers can-not be unrelated to their longer andmore effective methods of steriliza-tion, availability of potable water,influence of education, and high eco-nomic and social status. At least theycould afford to buy more than twobottles and teats, and more impor-tantly, the mothers could readily fol-low labeling instructions attached totheir sterilizing kits.

Thorough washing of teats and bot-tles with detergents and salts andadequate and prolonged sterilizationin milton water before use will greatlyreduce'the number of contaminatingbacteria and should improve thehealth of these babies. Advantages ofstoring bottles and teats in solutions

feeding utensils, diarrhea may also beprecipitated by contamination fromunhygienic methods and the lack ofpotable water used in reconstitutingformula, or contamination from han-dling the feeds or the feeding uten-sils:.16.17

Although many researchers haveshown the merits of breast-feeding;18.19the inherent dangers of bottle-feedingwith equipment that is heavily colo-nized by bacteria have not beenresearched widely in the tropicalcountries of Africa. Our study hasshown that teats used in feedingbabies were heavily contaminatedwith pathogenic bacteria like Salmo-nella, Shigella, EPEC, and S aureus,all of which have been implicated pre-viously in infantile gastroenteri-tis!o.21

As disclosed by most of the moth-ers, more than half of the childrenwhose feeding teats were investigatedhad suffered high episodes of diar-

Br Med J 1976;2:1326-1331.i6. Kendall"N, Vaughan VC, Kusakcioglu A: A

study of preparation of infant formulas. Am JDis Child 1971;122:215"219.

17. Soderhjelm L: Infant feeding hygiene inSweden. Acta Paediatr 1972;61:565-570.

18. Jelliffe DB, Jelliffe EFP: Human Milk inthe Modern World. London, Oxford UniversityPress, 1978.

19. Larguia AM, Urman J, Osvaldo A: Freshhuman colostrum for the prevention of E. colidiarrhoea: A clinical experience. J Trop PediatrEnviron Child Health 1977;23:289-290.

20; Middleton PJ: Rotavirus: Clinicalobserva-tion and diagnosis of gastroenteritis: .Compara-tive diagnosis of viral diseases.' 1977;1:423-444.

21. Schoub ED, Greef AS, Lacatsas G: Amicrobial investigation of acute summer gastro-enteritis in black South African infants. J Hyg1977;78:377-385.

References

8. Soderhjelm L: Infant feeding hygiene inSweden. Acta Paediatr Scand ):972;61:565-570;

9. D' Arca S: Contamination of infant feedingbottles and teats in Rome. Community Med1972;14:188-193.

10. Phillips I: Method and hygiene of infantfeeding in an urban area of Uganda. J TropPediatr Environ Child Health 1969;15:167-171.

11. Gatherer A, Wood N: Home standards ofsterilization of infant feeding bottles and teats.Monthly Bull Min Health Public Health Lab Serv1966;25:126.

12. Plank SJ, Milanesi ML: Infantfeeding andinfant mort~lity in rural Chile. Bull WHO1973;48:203-210.

13. Lennettee EH, Spaulding EH, Truant JP:Manual ojClinical Microbiology, ed 2. AmericanSociety for Microbiology 1974.

14. Bailey WR, Scott EG, Diagnostic Microbi-ology, ed 4. St Louis, CY Mosby Co, 1974.

15. Wharton BA, Berger HM: Bottle feeding.

1. Anderson JAD, Gatherer A: Hygiene ofinfant feeding utensils, practices and standard inthe home. Br Med J 1970;2:2-23.

2. Baumslag M, Kinse~ G, Sabin E: Breast isBest A Bibliography on Breast-Feeding and11I/a?1t Health. US Dept of Health, Education,and Welfare, 1978.

3. ;relliffe, DB: Approaches to village-levelinfant feeding: V. Artificial feeding with cow'smilk. J Trop Pediatr 1968;14:75-80.

4. Jelliffe DB: Paediatric practice in tropicalregions. Lancet 1965;1:229-231.

5. Omololu A: Significance of breast-feeding indeveloping countries. J Trop Pediatr EnvironChild Health 1975;21:270-273.

6. Paulo LR: Br~ast feeding in BraziLJ TropPediatr Environ Child Health 1975;21:209-217.

7. Mojekwa VI: Overview of the basic healthservices scheme. Presented at the Workshop onBasic Health Services Scheme, University of Ife,lIe-Ife, Nigeria, Jan 3, 1978.

674 Am J Dis Child-Vol 136, Aug 1982Infant Feeding Hygiene-Elegbe et al