Characterising infant and young child feeding practices and the consumption of poultry products in rural Tanzania: A mixed methods approach

Suboptimal breastfeeding practices, early initiation of complementary feeding, and monotonous cereal‐based diets have been implicated as contributors to continuing high rates of child undernutrition in sub‐Saharan Africa. Nutrition‐sensitive interventions, including agricultural programs that increase access to nutrient‐rich vegetables, legumes, and animal‐source foods, have the potential to achieve sustainable improvements in children's diets. In the quest to evaluate the efficacy of such programs in improving growth and development in the first 2 years of life, there is a role for mixed methods research to better understand existing infant and young child feeding practices. This analysis forms part of a longitudinal study assessing the impact of improvements to poultry health and crop production on diets and growth of 503 randomly selected children from eight rural communities in Manyoni District in central Tanzania. Using an explanatory sequential design, the quantitative phase of data collection was conducted between May 2014 and May 2016, comprising six monthly structured questionnaires, four monthly household‐level documentation of chicken and egg consumption, and fortnightly records of children's breastfeeding status. The subsequent qualitative phase involved in‐depth interviews with a subset of 39 mothers in October 2016. Breastfeeding was almost universal (96.8%) and of long duration (mean = 21.7 months, SD = 3.6), but early initiation of complementary feeding was also common (74.4%; mean = 4.0 months, SD = 1.8), overwhelmingly driven by maternal perceptions of insufficient milk supply (95.0%). Chicken and eggs were infrequently eaten, but close associations between maternal and child consumption patterns (p < .001) suggest the potential for strategies that increase household‐level consumption to bring nutritional benefits to young children.     

Dairy intensification,mothers and children: an exploration of infant and young child feeding practices among rural dairy farmers in Kenya

Agricultural strategies such as dairy intensification have potential to improve human nutrition through increased household food security. Increasing dairy productivity could also adversely affect infant and young child feeding (IYCF) practices because of increased maternal stress, demands on maternal time, and beliefs about the timing and appropriate types of complementary foods. Yet, few studies have looked rigorously at how interventions can affect young children (0–60 months). The study explores, within the context of rural dairy farming in Kenya, the relationship between level of household dairy production and selected IYCF practices using a mixed‐methods approach. Six focus group discussions with women involved in dairy farming investigated their attitudes towards breastfeeding, introduction of complementary foods and child diets. Ninety‐two households involved in three levels of dairy production with at least one child 0–60 months participated in a household survey. Quantitative results indicated that women from higher dairy producing households were more likely to introduce cow's milk to infants before they reached 6 months than women from households not producing any dairy. Themes from the focus group discussions demonstrated that women were familiar with exclusive breastfeeding recommendations, but indicated a preference for mixed feeding of infants. Evidence from this study can inform nutrition education programmes targeted to farmers participating in dairy interventions in rural, low‐income settings to minimise potential harm to the nutritional status of children.     

Local versus offshore production of ready‐to‐use therapeutic foods and small quantity lipid‐based nutrient supplements

Manufacturers on four continents currently produce ready‐to‐use therapeutic foods (RUTF). Some produce locally, near their intended users, while others produce offshore and ship their product long distances. Small quantity lipid‐based nutrient supplements (SQ‐LNS) such as Nutriset's Enov'Nutributter are not yet in widespread production. There has been speculation whether RUTF and SQ‐LNS should be produced primarily offshore, locally, or both. We analyzed The United Nations Children's Fund (UNICEF) Supply Division data, reviewed published literature, and interviewed local manufacturers to identify key benefits and challenges to local versus offshore manufacture of RUTF. Both prices and estimated costs for locally produced product have consistently been higher than offshore prices. Local manufacture faces challenges in taxation on imported ingredients, low factory utilization, high interest rates, long cash conversion cycle, and less convenient access to quality testing labs. Benefits to local economies are not likely to be significant. Although offshore manufacturers offer RUTF at lower cost, local production is getting closer to cost parity for RUTF. UNICEF, which buys the majority of RUTF globally, continues to support local production, and efforts are underway to narrow the cost gap further. Expansion of RUTF producers into the production of other ready‐to‐use foods, including SQ‐LNS in order to reach a larger market and achieve a more sustainable scale, may further close the cost and price gap. Local production of both RUTF and SQ‐LNS could be encouraged by a favorable tax environment, assistance in lending, consistent forecasts from buyers, investment in reliable input supply chains, and local laboratory testing.     

Mixed‐methods study identifies key strategies for improving infant and young child feeding practices in a highly stunted rural indigenous population in Guatemala

Guatemala's rural indigenous population suffers from one of the highest rates of chronic child malnutrition (stunting) in the world. Successfully addressing stunting requires defining the barriers to and opportunities for new behaviour‐change initiatives. We undertook a mixed‐methods assessment of feeding practices and food purchasing behaviours around infants and young children aged 6–36 months in two rural indigenous Guatemalan communities. We found that most caregivers were aware only of acute forms of child malnutrition and that they greatly underestimated the local prevalence of malnutrition. Despite moderate adherence to exclusive breastfeeding and timing of complementary food introduction, diets had poor diversity and inadequate meal frequency. Furthermore, perceptions of food insecurity were high even in the presence of land ownership and agricultural production. Although fortified foods were highly valued, they were considered expensive. At the same time, proportionally equivalent amounts of money were spent on junk foods or other processed foods by most participants. Biological mothers often lacked autonomy for food purchasing and nutritional decisions because of the power exerted by husbands and paternal grandmothers. Our findings suggest several creative and community‐based programming initiatives including education about the acute vs. chronic malnutrition distinction, engaging landowners in discussions about domestic food consumption, engaging with caregivers to redirect funds towards fortified foods rather than junk food purchases and directing behaviour‐change initiatives towards all household stakeholders.     

Complementary feeding practices and child growth outcomes in Haiti: an analysis of data from Demographic and Health Surveys

The Haitian National Nutrition Policy identifies the promotion of optimal complementary feeding (CF) practices as a priority action to prevent childhood malnutrition. We analysed data from the nationally representative 2005–2006 Haiti Demographic Health Survey using the World Health Organization 2008 infant and young child feeding indicators to describe feeding practices among children aged 6–23 months and thus inform policy and programme planning. Multivariate regression analyses were used to identify the determinants of CF practices and to examine their association with child growth outcomes. Overall, 87.3% of 6–8‐month‐olds received soft, solid or semi‐solid foods in the previous 24 h. Minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) were achieved in 29.2%, 45.3% and 17.1% of children aged 6–23 months, respectively. Non‐breastfed children were more likely to achieve MDD than breastfed children of the same age (37.3% vs. 25.8%; P < 0.001). The proportion of children achieving MMF varied significantly by age (P < 0.001). Children with overweight mothers were more likely to achieve MDD, MMF and MAD [odds ratio (OR) 2.08, P = 0.012; OR 1.81, P = 0.02; and OR 2.4, P = 0.01, respectively] than children of normal weight mothers. Odds of achieving MDD and MMF increased with household wealth. Among mothers with secondary or more education, achieving MDD or MAD was significantly associated with lower mean weight‐for‐age z‐score and height‐for‐age z‐score (P‐value <0.05 for infants and young child feeding indicator × maternal education interaction). CF practices were mostly inadequate and contributed to growth faltering among Haitian children 6–23 months old.     

Impact of infant feeding practices on the risk of mother to child transmission of HIV-1 in Zimbabwe

OBJECTIVE: To determine the magnitude of the contribution of infant feeding practices on the risk of mother to child transmission (MTCT) of the HIV-1 infection. METHODOLOGY: Prospective data from birth until 24 months of age on 236 infants born to HIV-positive mothers in Harare, Zimbabwe was analysed for this study. However, because only a small proportion of infants (2.1%) were HIV-1 polymerase chain reaction (PCR) tested shortly after birth, the PCR results for infants at birth were not incorporated into our analyses. The contribution of infant feeding practices on the risk of MTCT of HIV-1 was assessed using Cox Proportional Hazards Regression Models. RESULTS: The incidence of HIV-1 through MTCT was greatest among breastfed (8.33 per 100 child-months) and mixed fed (8.64 per 100 child-months) infants by 3 months. After adjustment for maternal age, marital status, education and infant antibody HIV-1 status, the cumulative relative risk of MTCT of HIV-1 was 4.19 (95% confidence interval (CI) 3.44, 5.09) among breastfed and 1.10 (95% CI 0.97, 1. 25) among mixed fed infants. The overall MTCT rate of HIV-1 in this study was 40.3%. CONCLUSIONS: Breastfed infants had the greatest cumulative relative risk of MTCT of HIV-1, followed by mixed fed infants, with the highest incidences occurring within the first 3 months.     

Effectiveness of an educational intervention to improve child feeding practices and growth in rural China: updated results at 18 months of age

Inappropriate complementary feeding practices have led to, in part, significant disparities in growth and nutritional status between rural and urban children in China. A cluster‐randomised, controlled trial was implemented in Laishui, China to assess the effectiveness of an educational intervention on caregivers' feeding practices and children's growth. Eight townships were randomly assigned to the intervention or control. Five hundred ninety‐nine healthy infants were enrolled at 2–4 months old, and were followed up at ages 6, 9, 12, 15 and 18 months. The intervention group received information on enhanced home‐prepared recipes and food preparation and hygiene through group training, counselling and home visit. Key outcomes were children's physical growth, caregivers' knowledge and behaviours on complementary feeding, and the infant and child feeding index (ICFI). Analysis was by intention to treat. The intervention group achieved better knowledge and practices related to complementary feeding, and significantly higher ICFI scores at each follow‐up point. Children in the intervention group achieved higher z‐scores for weight‐for‐age (WAZ) and weight‐for‐height (WHZ) than the control (0.18 vs. 0.01 and 0.49 vs. 0.19, respectively) at 18 months old, and were less likely to have stunted growth (odds ratio = 0.71, 95% confidence interval: 0.53–0.94). Mixed model showed that the intervention group achieved significantly better linear growth over time, including WAZ (P = 0.016), WHZ (P = 0.030) and HAZ (P = 0.078). These results indicated that an educational intervention delivered through local health services can enhance caregivers' knowledge and practices of complementary feeding and ultimately improve children's growth.     

Complementary feeding practices and associated factors of dietary diversity among uncomplicated severe acute malnourished children aged 6–23 months in Burkina Faso

Nutritional treatment of children with uncomplicated severe acute malnutrition (SAM) is based on ready‐to‐use therapeutic foods (RUTF). With treatment provided at community level, children could have access to other foods, and a reduction in the dose of RUTF could further increase dietary diversity during treatment. We assessed the dietary diversity score (DDS), the minimum dietary diversity (MDD), the minimum meal frequency (MMF) and the minimum acceptable diet (MAD) of 459 infants and young children aged 6–23 months being treated for SAM with different doses of RUTF. We also investigated the factors associated with DDS. Dietary intake was estimated using a single 24‐h multipass dietary recall, 1 month after starting treatment, from December 2016 to August 2018. The DDS was calculated on the basis of eight food groups. Differences between children receiving the reduced RUTF and the standard RUTF dose and factors associated with DDS were assessed by Poisson and logistic regression models. RUTF dose was not associated with DDS (4.07 ± 1.25 for reduced RUTF and 4.01 ± 1.26 for standard RUTF; P = 0.77). Food groups most consumed by children were grains, roots or tubers (96%) and legumes and nuts (72%). Eggs consumption was low (3%). DDS was positively associated with child''s age, mother''s education, household wealth index, urban residence and rainy season. The present findings show that children with SAM consumed a variety of foods during treatment in addition to the RUTF ration prescribed to them. Reducing the dose of RUTF during SAM treatment did not impact DDS.     

Evolution of infant feeding practices in children from 9 to 24 months,considering complementary feeding indicators and food processing: Results from the Brazilian cohort of the MAL‐ED study

Infant feeding practices impact children''s nutritional and health status, influencing growth and development. This study aimed to analyse the evolution of infant feeding practices from 9 to 24 months of age, considering infant and young child feeding (IYCF) indicators and food processing. The infant feeding practices in children from the Brazilian site of the MAL‐ED study were evaluated at 9 (n = 193), 15 (n = 182) and 24 months (n = 164) using 24‐h dietary recalls. IYCF indicators were evaluated, and the extent of food processing was evaluated, using the NOVA classification. Breastfeeding declined significantly over time, from 77.6% at 9 months to 45.1% at 24 months. Although dietary diversity did not significantly change during the study period (80.5% at 24 months), the minimum acceptable diet significantly increased from 67.9% to 76.1% at 24 months (p < 0.0005). All the studied children consumed sweetened beverages from 9 months. Unhealthy food consumption and zero vegetable or fruit consumption significantly increased over time (p < 0.0005). Unprocessed food consumption decreased from 9 to 24 months of age (p < 0.0005), while ultra‐processed food consumption increased (p < 0.0005) during the study period. Logistic regressions showed that, at 9 months, breastfed children presented a lower risk for ultra‐processed food consumption (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.13–0.77); and children reaching the minimum acceptable diet presented more risk for ultra‐processed food consumption (OR = 2.31; 95% CI = 1.01–5.27). In conclusion, data showed a reduction in the quality of infant feeding practices over the first 2 years of life, with a decrease in breastfeeding and an increase in the consumption of unhealthy and ultra‐processed foods.     

Poor dietary diversity and low nutrient density of the complementary diet for 6‐ to 24‐month‐old children in urban and rural KwaZulu‐Natal,South Africa

Infants and toddlers have high nutritional requirements relative to body size but consume small amounts of food and therefore need nutrient‐dense complementary foods. A cross‐sectional study included children aged 6–24 months, stratified in three age categories (6–11 months, 12–17 months and 18–24 months) and randomly selected from an urban (n = 158) and a rural (n = 158) area, both of low socio‐economic status, in the KwaZulu‐Natal Province of South Africa. Dietary diversity and nutrient density of the complementary diet (excluding breast milk and formula milk) based on a repeated 24‐h dietary recall was assessed. For breastfeeding children, nutrient density of the complementary diet was adequate for protein, vitamin A and vitamin C; and inadequate for 100% of children for zinc, for >80% of children for calcium, iron and niacin; and between 60% and 80% of children for vitamin B6 and riboflavin. Urban/rural differences in density for animal and plant protein, cholesterol and fibre occurred in 18–24‐month‐old children. Fewer than 25% of children consumed ≥4 food groups, with no urban/rural differences. Higher dietary diversity was associated with higher nutrient density for protein and several of the micronutrients including calcium, iron and zinc. The poor nutrient density for key micronutrients can probably be ascribed to lack of dietary variety, and little impact of mandatory fortification of maize meal/wheat flour on infants/toddlers' diet. Targeted strategies are needed to enable mothers to feed their children a more varied diet.     

Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready‐to‐use therapeutic foods

Outpatient therapeutic feeding protocols for the treatment of uncomplicated severe acute malnutrition in children were initially based on weight gain data from inpatient settings and expert knowledge of the physiological requirements during recovery. However, weight gain and energy requirements from historic inpatient settings may differ from modern outpatient settings and therefore may not be appropriate to guide current therapeutic feeding protocols. We calculated the weight gain and average estimated total daily energy requirement of children successfully treated for uncomplicated severe acute malnutrition as outpatients in Niger (n = 790). Mean energy provided by six therapeutic feeding protocols was calculated and compared with average estimated energy requirements in the study population. Overall weight gain was 5.5 g·kg^?1·day^?1 among recovered children. Average energy requirements ranged from 92 to 110 kcal·kg^?1·day^?1 depending on the estimation approach. Two current therapeutic feeding protocols were found to provide an excess of energy after the first week of treatment in our study population, whereas four research protocols tended to provide less energy than the estimated requirement after the first week of treatment. Alternative feeding protocols have the potential to simplify and lead to important savings for programmes but should be evaluated to show adequacy to meet the energy needs of children under treatment, as well as feasibility and cost efficiency. Our findings rely on theoretical calculations based on several assumptions and should be confirmed in field studies.     

Formative research to explore the acceptability and use of infant food grinders for the promotion of animal source foods and micronutrient powders in rural Peru

According to global recommendations, quality diets for complementary feeding (CF) should include a diversity of foods including vitamin A‐rich fruits and vegetables and sources of high‐quality proteins and essential nutrients, particularly animal‐source foods (ASF). A key barrier to feeding ASF surrounds beliefs that the preparation of foods of a thicker consistency may cause problems of digestion, “heaviness” or stomach problems, swallowing, and choking. The objective of this study was to explore, through systematic formative research, the acceptability, use, and feasibility of a simple technology, commercial infant food grinders, in two rural Peruvian settings where there is delayed and low consumption of complementary foods of a thick consistency, including ASF. Phase I explored the barriers, constraints, and opportunities related to the provision of foods of a thicker consistency with a focus on ASF. Phase II encompassed household behavioural trials with mothers and infants to assess the acceptability and use of the grinders in the home setting, using key concepts and messages developed from the information obtained during Phase I. The technology was highly acceptable, used by the majority of mothers (87.8%), and led to changes in cultural perceptions, facilitating increased feeding of appropriate textures (thick purees), ASF, and multimicronutrient powders. Energy, protein, and micronutrient intakes were all significantly greater after the household behavioural trials. This simple technology, paired with systematic formative research to appropriately promote its use across cultures, may have a significant effect on improving CF practices globally, particularly for young infants beginning CF at 6 months.     

An integrated infant and young child feeding and small‐quantity lipid‐based nutrient supplementation programme in the Democratic Republic of Congo is associated with improvements in breastfeeding and handwashing behaviours but not dietary diversity

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ‐LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ‐LNS to improve IYCF practices, and ultimately children's nutritional status.