RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Ms. GRACE ALEXANDER

I Year M.Sc Nursing
Child Health Nursing
Year 2009 - 2011

PADMASHREE INSTITUTE OF NURSING

BANGALORE
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE Ms. Grace Alexander

CANDIDATE AND I Year M. Sc Nursing
ADDRESS Padmashree Institute of Nursing,
Bangalore.
2. NAME OF THE Padmashree Institute of Nursing,
INSTITUTION Bangalore

3. COURSE OF STUDY AND I Year M.Sc nursing,

SUBJECT Child Health Nursing

4. DATE OF ADMISSION TO 19-06- 2009

COURSE

5. TITLE OF STUDY Assessment of effectiveness of

structured teaching program on
knowledge regarding prevention and
management of gastroenteritis among
mothers of bottle-fed infants.

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6. BRIEF RESUME OF THE INTENDED WORK:

6.1 INTRODUCTION

All children have three important needs to help achieve their full potential-a
feeling that they are loved, that their hunger is satisfied, and that they have freedom
from infection. Thus, appropriate feeding is crucial for the healthy growth and
development of the infant. The health and survival of the infant depends on the
awareness, education and skills of the mother including feeding practices, hygiene and
prevention of infection.

An informed decision about an infant's diet should be based on healthcare

professional advice as well as the parents' lifestyles and preferences. Choosing
whether to breastfeed or formula feed the baby is one of the first decisions expectant
parents will make. The American Academy of Pediatrics (AAP) joins other
organizations such as the American Medical Association (AMA), the American
Dietetic Association (ADA), and the World Health Organization (WHO) in
recommending breastfeeding as the best for babies. The AAP says babies should be
breastfed exclusively for the first 6 months. Beyond that, the AAP encourages
breastfeeding until at least 12 months, and longer if both the mother and baby are
willing.

It is now a well understood concept that breastmilk is the ideal milk for infants
as it has many anti-infective factors which prevent the child from various bacterial and
viral infections. The presence of these factors help the breastfed child to have less
incidence of gastroenteritis than artificially fed babies. The bifidus factor found in
breast milk, helps a special bacteria called Lactobacillus bifidus to grow in the baby’s
intestine which in turn prevents other harmful bacteria from growing and causing
gastroenteritis.1

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 However, in certain conditions like acute febrile maternal illness, mothers
receiving antithyroid drugs, anticancer drugs, debilitating chronic illness, it is
contraindicated to breast-feed their babies either temporarily or permanently. Working
mothers need to supplement breast-feeding with artificial feeds because of social
constraints of breastfeeding. Bottlefeeding may also be required when lactation is
inadequate or mother has twin or triplet babies. But it can be potentially hazardous for
the baby as it can lead to infections such as acute gastroenteritis or repeated diarrhea. 2

Gastroenteritis is defined as the passage of loose, liquid or watery stools, more

than three times per day, caused due to inflammation of mucosa of the stomach and
small intestine. The recent change in consistency and character of stool rather than
number of stools is more important. Especially in children one large amount of watery
motion may constitute gastroenteritis.

‘Acute gastroenteritis’ is an attack of loose motion with sudden onset which

usually lasts 3 to 7 days but may last upto 10-14 days. It is caused by an infection of
the large intestine, but may be associated with infection of gastric mucosa and small
intestine. The term ‘acute gastroenteritis’(AGE) is most frequently used to describe
acute diarrhoea.3

Chronic gastroenteritis is termed in condition when the loose motion is

occurring for 3 weeks or more. It is usually related to underlying organic diseases with
or without malabsorption. Persistent diarrhoea refers to episodes of acute diarrhoea
that last for 2 weeks or more and may be due to infective origin. 4

Prevention of gastroenteritis due to inappropriate feeding practices is a very

important step in reducing infant mortality and morbidity. It includes proper
sterilization or cleaning of bottles, hygienic preparation of feeds, avoiding
contamination of bottles by leftover milk leading to bacterial infection and correct
preparation of formula feeds. 5

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6.2 NEED FOR THE STUDY:

Gastroenteritis is one of the leading causes of infant morbidity and mortality.

Diarrhoeal diseases rank among the top three causes of childhood death in the
developing countries. On an average a child suffers from about 12 episodes of
gastroenteritis, 4 such episodes occurring during the very first year of life. The two
main dangers of gastroenteritis are malnutrition and death. 6

The Department of Health recommends exclusive breastfeeding for the first

six months as research studies show that formula fed babies are five times more
likely to be admitted to hospital with gastroenteritis.

Breast milk was shown to have a number of short- and long-term benefits, but
the most frequently cited benefit is for a lower incidence of gastroenteritis in infants
breastfed rather than formula-fed . Several factors were suggested to contribute to this
protective effect including, eg, a higher concentration of nucleotides in human milk
compared with cow-milk-based formula. Nucleotides are nonprotein nitrogenous
compounds suggested to be essential nutrients in certain clinical conditions, to
modulate immune function, and to be important for growth, repair, and differentiation
of the gastrointestinal tract. In vitro studies suggest that nucleotides enhance the
growth of bifidobacteria , which by reducing stool pH could reduce the growth of
pathogenic bacteria and hence the incidence of gastroenteritis. Bifidobacterium spp.
are found in higher proportions in the stools of breastfed compared with formula-fed
infants. 7
From in-vitro studies of breastmilk and formula feed preparations, and of the
faeces from breast-fed and bottle-fed infants, a number of factors seemed likely to
influence the production and maintenance of a lactobacillary flora and low pH in the
faeces of newborn infants which are responsible for prevention of gastroenteritis.
These were mainly attributable to the nature of the feed. It is suggested that
responsible factors in breast milk include its high lactose, low protein, low phosphate

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content, together with its poor buffering capacity. Importance is also attached to the
fact that breast milk seems to provide a fluid feed of small bulk and low residue, and
that its use is unlikely to include periods of starvation. These factors contribute to
resistance of the breast fed infant to gastroenteritis. Formula feed preparations, on the
other hand, which has a low lactose, high protein, high phosphate content, and a high
buffering capacity, is a relatively bulky, high-residue feed. Feeding regimens which
employ it are likely to include periods of starvation.
Bottle-feeding is the biggest killer of babies in the developing countries.
Bottle-fed babies have 2 to 7 times increased risk of mortality compared to breast-fed
babies, due to low incidence of infective gastroenteritis, necrotizing enterocolitis,
respiratory infections and many other conditions 8
According to World Health Organisation (WHO), over two-thirds of under-
five deaths, are associated with inappropriate feeding practices occurring during the
first year of life. Under normal circumstances, infants who are not breast-fed are 14
times more likely to die from gastroenteritis, than infants who are exclusively
breastfed for the first 6 months.
Most cases of gastroenteritis are self-limiting and do not require
hospitalization. Therefore knowledge of mothers regarding management of
gastroenteritis at home is very important. Management includes accurate monitoring
of intake and output and successful replacement of lost fluid. Strict medical asepsis
and infection control precautions are necessary to prevent infection related
gastroenteritis in bottle-fed infants. Proper cleaning, washing, boiling, handling of
bottles and preparation or storage of milk is important to prevent infections.8
In light of the above facts, with personal experience of the investigator,
working as staff in caring for infants have encountered many mothers with
complaints of recurrent gastroenteritis, especially in bottle-fed infants. Therefore, this
has created interest in investigator to provide a structured teaching programme on
prevention and management of gastroenteritis to mothers of bottle-fed infants.

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6.3 STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of structured teaching program on
knowledge regarding management and prevention of gastroenteritis in bottle-fed
infants among mothers at selected urban community, Bangalore.

6.4 OBJECTIVES:

1. To assess the pretest knowledge regarding management and prevention of

gastroenteritis in bottle-fed infants among mothers.

2. To assess the posttest knowledge regarding management and prevention of

gastroenteritis in bottle-fed infants among mothers.

3. To compare pre-test and post-test knowledge regarding management and

prevention of gastroenteritis in bottle-fed infants among mothers.

4. To associate the pre-test knowledge regarding management and prevention of

gastroenteritis in bottle-fed infants among mothers with their selected demographic

variables.

6.5 OPERATIONAL DEFINITIONS:

1) Effectiveness:

It refers to the extent to which structured teaching program on management and

prevention of gastroenteritis is effective in improving knowledge among mothers
of bottle-fed infants.

2) Structured Teaching Program:

It refers to systematically organized, individualized instruction and discussion

prepared to educate mothers of infants with the help of AV Aids regarding
management and prevention of gastroenteritis- such as general information on
gastroenteritis, ways to prevent it, hygienic bottle-feed practices, and home
management of gastroenteritis.
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 3) Knowledge:
It refers to the level of understanding regarding management and prevention of
gastroenteritis among mothers of bottle-fed infants.

4) Gastroenteritis:

Gastroenteritis is defined as the passage of loose, liquid or watery stools, more

than three times per day.

5) Mothers of bottle-fed infants:

It refers to mothers having children upto one year of age who are practicing bottle-
feeding.

6.6 ASSUMPTIONS:

1. Mothers may have inadequate knowledge regarding prevention and management

of gastroenteritis.

2. Infants who are bottle-fed are more at risk for gastroenteritis

3. Structured teaching program on prevention and management of gastroenteritis may

help mothers in improving their knowledge and thereby reduce complications

6.7 RESEARCH HYPOTHESIS:

H1: There may be significant difference between the mean pretest and post test
knowledge of mothers regarding management and prevention of gastroenteritis in
bottle-fed infants
H2: There may be significant association between pre-test knowledge of mothers
regarding management and prevention of gastroenteritis in bottle fed infants with

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 their selected demographic variables.

6.8 REVIEW OF LITERATURE:

A retrospective study was done on infant feeding based on duration of breast-

feed, time of introduction and duration of bottle-feed in 683 infants. The infants were
classified into one of five feeding groups for comparing risk of developing
gastroenteritis during the first year of life between the exclusively bottle-fed and each
of the other four feeding groups. In the study, a trend of decreasing gastroenteritis with
increasing breast feeding was noted across all other feeding groups. Thus, exclusive
breast feeding for four months is associated with reduced risk of early first episodes of
gastroenteritis among infants in a less developed community in the United States.9

A study was done to examine the relationship between the feeding type and
hospitalization for gastroenteritis, in 3285 infants in Shanghai. Infants were classified
into "ever" and "never" breastfeeding groups. In the study, the risk of hospitalization
for gastroenteritis in the ever breastfed infants was significantly lower than that in the
never breastfed infants, 3.4 percent versus 5.3 percent. The data suggest that
breastfeeding offers moderate protection against hospitalization for gastroenteritis in
Shanghai infants.10

A prospective study was done to determine relationship of mode of infant

feeding and location of care to frequency of infection in 200 full-term infants. Infants
were categorized by mode of feeding - breast, breast and bottle, or bottle; and were
subcategorized by location of care. The average number of infections in infants fed in
a day-care or sitter location was 35% greater than that in infants fed at home. The
mode of feeding also had significant influence on frequency of infection. The rate of

9
infections recorded in bottle-fed infants was found to be 17% more than that of breast
fed infants.11

A cross-sectional study was done to assess the relationship between nutritional

status, feeding practices and diarrhoeal diseases in 50 infants who had gastroenteritis.
Information was obtained from mothers in a hospital setting concerning feeding
practices, age and sex of the infant, quality of the water supply, and whether water
used for feeding was boiled. Infants were weighed and examined to determine the
degree of malnutrition. It was found that better nutrition and supplementation of water
in addition to feeds were inversely associated with the occurrence of gastroenteritis.
Breast-fed infants were better nourished than formula-fed infants. More informatively,
we find that significantly fewer exclusively breast-fed infants (28%) suffer from
malnutrition compared to formula-fed infants (66%). These findings underscore the
importance of adequate nutrition, feeding practices and hygiene in reducing rates of
infant morbidity.12

A study was conducted to measure the impact of bottle-feeding on nutrition

related gastroenteritis in North Yemen. In the study 510 mothers and their infants,
attending an urban health center were studied. Only 21 per cent of all bottle-fed infants
received >60 kcal/kg body weight daily from milk. The study reveals that bottle-fed
infants under 6 months had a markedly increased risk of severe malnutrition due to
gastroenteritis over those fully breast-fed (16.2 per cent vs. 2.2 per cent). 13

A study was conducted to compare amounts ingested, administration time, and

infant physiologic stability during cup-, bottle-, and breastfeeding. In this study,
98 term, healthy newborns were randomized to either cup-feeding (n = 51) or bottle-
feeding (n = 47) and 25 breastfed newborns during 1 feeding. The heart (HR),
respiratory (RR), and oxygen (O2) saturation rates were monitored in these infants.
The study revealed that the administration times, amounts ingested, and infant

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physiologic stability do not differ with cup- and bottle-feeding. Breastfeeding takes
longer than cup- or bottle-feeding, but infants experience less physiologic variability.14

A study was conducted to identify the current trends in bottle feeding practices
with a view to encourage breast feeding and to reduce bottle feeding practices so that
child morbidity and mortality can be reduced in an urban slum in the city of Thane
(Maharashtra). In this study, mothers of 252 children aged 24 months or less were
interviewed regarding bottle feeding. It was found that 9.95% of the children received
cow’s milk and/or water through bottles. This category of babies belonged to 4 to 12
months age group. The bottle feeding rate was 9.95%. 60% of the mothers who
resorted to bottle feeding, were working. The most common reason given (by 85.34%
of the housewives) for bottle feeding was that their breast milk was inadequate. Some
housewives also felt that bottle feeding was a convenient method of feeding.15

A study was conducted to examine the etiology, clinical, analytical and

evolutionary characteristics of gastroenteritis in the pediatric population below three
years of age in the Emergency Department of Dr. Peset University Hospital in Spain
in 794 children. Their stools were examined for diarrheagenic bacteria and viruses
(rotavirus and adenovirus). It was found that among infants < or = 6 months of age
rotavirus was less frequent as cause of gastroenteritis in breast-fed infants than in
bottle-fed. Rotavirus was significantly more associated with the need for intravenous
fluid therapy and hospitalisation than episodes negative for rotavirus and accounted
for 3 % of hospitalisation in infants aged 1 month-2 years.16

A study was conducted to find clinical and epidemiological description of acute

intestinal infections in children of the lower Volga region, Russia. In accordance with
the results of laboratory diagnostics, carried out by bacteriological, serological and
PCR methods, the etiological structure of acute bacterial and viral intestinal
infections, most frequently occurring in children aged up to 2 years was found.
Results revealed that infections affect mainly children given artificial feeding than

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 breast feeding, as well as those with complicated premorbid state and frequently
having acute respiratory viral infections.17

A study was conducted to find the relation of Adoption and hospital admission in
Port Moresby General Hospital, Papua New Guinea in the year 2000. The study
revealed that Gastroenteritis and neonatal sepsis were more common causes of
admission in adopted children than in the general paediatric hospital population. The
proportion of hospitalized children known to be adopted was almost three times that in
the children's outpatients department. 82.5 per cent of the adopted children had been
bottle fed compared with 13.75 per cent of the control.18

A prospective study was conducted to detect the effect of feeding practice, in

particular the role of artificial milk formulae, in children admitted with
hypernatraemic dehydration caused by acute gastro-enteritis, and to record morbidity
and mortality in these patients. Sixty-seven children aged 18 days to 18 months
admitted during the study with acute gastro-enteritis were studied. Twenty-four
infants (36%) with hypernatraemic dehydration were on evaporated cow's milk
powder compared to five hypernatraemic infants (7.5%) who were breastfed.
Artificial milk feeding, particularly the use of evaporated cow's milk powder, is a
predisposing factor for hypernatraemia in infantile gastro-enteritis. This study
emphasizes the importance of breast-feeding and the need to educate mothers to avoid
giving evaporated cow's milk formulae to babies under 1 year of age if breast-feeding
is not possible.19

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

The data will be collected from mothers of infants who are residing in
selected urban community, Bangalore.

7.2 METHOD OF DATA COLLECTION

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 i. Research Design
Quasi experimental: one group pretest posttest design

ii. Research Variables

Dependent Variable:
Level of knowledge of mothers on management and prevention of
gastroenteritis in bottle-fed infants.
Independent Variable:
Structured teaching program on management and prevention of
gastroenteritis among mothers of bottle-fed infants.

iii. Setting
The study will be conducted in selected urban community under Kengeri
Uppanagara primary health centre, Bangalore.

iv. Population

Mothers of infants who are bottle-fed and live in selected urban community
at Bangalore.

v. Sample Size
Mothers of infants who fulfill inclusion criteria and the sample size will be 60.

vi. Criteria for Sample Selection

Inclusion Criteria: The study includes
i. Mothers practicing bottle-feeding for their infants.
ii. Mothers who can understand Kannada or English.
iii. Mothers who are willing to participate in the study.

Exclusion Criteria: The study excludes

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 i. Mothers who are not available at the time of data collection
ii. Mothers practicing exclusive breast-feeding for their infants.

vii. Sampling Technique

Non-probability convenience sampling technique

viii. Tool for Data Collection

The tool consists of three sections:

Section A:

Demographic performa of mothers consisting of age, education,

occupation, monthly income, religion, type of family, type of house,
number of children, type of feeding and sources of information.

Demographic performa of infant consisting of age, previous history

of gastroenteritis, hospitalization, duration of illness, onset and type of

refeeding.

Section B:
Structured teaching programme on management and prevention of
gastroenteritis in bottle-fed infants among mothers.
Section C:
Structured questionnaire will be used to assess the knowledge on
management and prevention of gastroenteritis in bottle-fed infants among
mothers.

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 ix. Methods for Data Collection

After obtaining the permission from the concerned authorities and informed
consent from samples, the investigator will collect the data by using structured
interview schedule in following three phases.

Phase I: Pre test will be given to assess the existing knowledge of mothers on
prevention and management of gastroenteritis in bottle-fed infants with the help of
structured questionnaire.

Phase II: On the same day structured teaching program will be given to mothers
on prevention and management of gastroenteritis in bottle-fed infants by using
flash cards for 45 min to 1 hr duration.

Phase III:Post-test will be conducted to assess post-test knowledge with the help
of same questionnaire among mothers on prevention and management of
gastroenteritis after 7 days of implementation of structured teaching programme.

Duration of the data collection is 4-6 weeks.

x. Plan for Data Analysis

The data collected will be analyzed by means of descriptive and inferential

statistics.

Descriptive statistics:
Frequency and percentage distribution will be used to analyze the
demographic variables. Mean and standard deviation will be used to analyze the
level of knowledge of mothers regarding prevention and management of
gastroenteritis.

Inferential Statistics:
Paired-‘t’ test will be used to compare the pretest and posttest knowledge
regarding prevention and management of gastroenteritis among mothers of bottle-

15
 fed infants and Chi-square test will be used to associate posttest knowledge
regarding prevention and management of gastroenteritis among mothers of bottle-
fed infants with selected demographic variable.

xi. Projected Outcome

Structured teaching will improve the knowledge of mothers regarding

prevention and management of gastroenteritis in bottle-fed infants. This will
enable the mothers to follow hygienic feeding practices thus minimizing
gastroenteritis in infants.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO

THE PATIENTS OR OTHER HUMAN BEINGS?

Yes, structured teaching program will be administered for mothers on prevention

and management of gastroenteritis in bottle-fed infants in selected urban community at
Bangalore.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM THE INSTITUTION?

Yes, formal permission will be obtained from the authorities. Informed consent
from the samples will be obtained. Confidentiality and privacy of data will be maintained.

8. LIST OF REFERENCES:

1. Parthasarathy A. IAP textbook of paediatrics. 3rd edition. Jaypee Publications; 2008.

2. Nicki L. Potts, Barbara L. Mandleco, Paediatric nursing: Caring for children and their

families. 2nd edition. Thomson delmar learning; 2007.

16
3. Parul Dutta. Paediatric nursing. 1st edition. Jaypee Brothers Publication; 2008.

4. O.P. Ghai, Piyush Gupta, V.K. Paul. Ghai Essential Paediatrics. 6 th edition. CBS

Publication; 2005.
5. Marilyn J. Hockenberry, David Wilson. Wong’s nursing care of infants and children.

8th edition. Mosby Elsevier Inc; 2007.

6. Suraj Gupte. The shortbook of paediatrics. 10th edition. Jaypee Publication; 2004.

7. Dorothy R. Marlow, Barbara A. Redding. Textbook of paediatric nursing. W.B.

Saunders Company; 2005.

8. Meharban Singh. Care of the newborn. 6th edition. Brand Stewards Pvt. Ltd; 2004,.

9. Fred Agre. The relationship of mode of infant feeding and location of care to

frequency of infection. Journal of paediatric gastroenterology and nutrition 1985;

139(8):809-11.
10. Yue Chen. Relationship between type of infant feeding and hospitalization for

gastroenteritis in Shanghai infants. Journal of human lactation 1994; 10 (3): 177-79.

11. M. R. Forman, B. I. Graubard, H. J. Hoffman, R. Beren, E. E. Harley, P. Bennett. The

pima infant feeding study: breast feeding and gastroenteritis in the first year of life.
Journal of epidemiology 1984; 119(9): 335–49.
12. C. Fertleman, G. R. Bentley. Factors predisposing infants to gastroenteritis among
poor, urban, filipino families. The internet journal of pediatrics and neonatology
2003; 3 (1):223-29
13. Clifford B. David, Patricia Hallett David. Bottle-feeding and malnutrition in a
developing country: the ‘bottle-starved’ baby. Journal of tropical pediatrics 30(3):
159-164
14. Cynthia R. Howard, Elisabeth A. de Blieck, Cynthia B. ten Hoopen, Fred M. Howard,

Bruce P. Lanphear, Ruth A. Lawrence. Physiologic stability of newborns during

breast-, cup- and bottle-feeding. Journal of paediatrics 1999; 104(5): 1204-7.

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15. R Gourav, S Kartikeyan, J Kale. Trends in bottle feeding in an urban slum. Indian
journal of peadiatrics 2006; 12(2): 127-31.
16. Munoz Vicente E, Breton Martinez JR, Ros Diez A, Rodriguez Garcia A, Casado,
Sanchez B, Hernandez Marco R, Nogueira Coito JM. Infectious acute gastroenteritis
in the emergency department of an urban hospital. Journal of paediatrics 2008;
68(5):432-8
17. Burkin AV, Kharchenko GA. Clinical and epidemiological description of acute
intestinal infections in children below two years. Journal of epidemiology
immunology 2006; 47(1):69-72.
18. Pameh W, Ripa P, Vince J, Mueller I. Adoption and hospital admission in Port
Moresby, Papua New Guinea. Journal of tropical pediatrics 2002; 48(5): 264-9.
19. Abu-Ekteish F, Zahraa J. Effect of feeding practice and acute gastro-enteritis in
children. Journal of tropical paediatrics 2002; 22(3): 245-9.
20. Polit F. Beck. Nursing Research-Generating and assessing evidence for nursing
practice. 8th edition. Wolters Kluwer;2008
21. Veerbala Rastogi. Fundamentals of biostatistics: data analysis. New Delhi: Anes
books India; 2008.

9. Signature of the candidate :

10. Remarks of the guide :

11.1 Name and designation of Guide : Mrs. Bhima Uma Maheshwari

Associate Professor

11.2 Signature :

11.3 Co-Guide :

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11.4 Signature :

11.5 Head of Department : Mrs. Bhima Uma Maheshwari

11.6 Signature :

12.1 Remarks of the Principal :

12.2 Signature :

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