Infant and Young Child Feeding

Infant and Young Child Feeding: Comparison

Please note this is a comparison between Version 1 by Kingsley Emwinyore Agho and Version 2 by Karina Chen.

Appropriate infant and young child feeding (IYCF, comprising of breastfeeding and complementary feeding) play important roles in optimal child growth and development. This is because appropriate breastfeeding is associated with a lower prevalence of childhood diarrhea , upper respiratory tract infection and obesity, and maternal diseases like diabetes mellitus. Additionally, appropriate complementary feeding is associated with a reduced risk of undernutrition (i.e., underweight, stunting, and/or wasting). Despite the benefits of appropriate IYCF, many low- and middle-income countries (LMICs) still report higher prevalence of inappropriate IYCF. In India, inappropriate IYCF practices have contributed to childhood malnutrition contributing to about 68% of the under five deaths and 83% of the neonatal deaths . Inappropriate IYCF was the underlying source for an estimated 0.9 million under-five deaths in 2016. Inappropriate IYCF are feeding behaviors that do not meet the recommendations of the World Health Organization/United Nations Children’s Fund (WHO/UNICEF) indicators for assessing IYCF practices. Core WHO/UNICEF recommendations include the initiation of breastfeeding for newborns within the first hour of birth, followed by exclusive breastfeeding (EBF) for the first six months of birth, and continued breastfeeding for up to two years and more, with nutritionally-balanced and safe complementary foods introduced to the infant when the child is six months old.

infant and young child feeding
breastfeeding
complementary feeding
India

1. Introduction

o improve global infant and young child feeding, the WHO recently endorsed a set of Global Nutrition Targets (WHO GNT, including Goals 1, 5, and 6). These goals aim to reduce the number of stunted children by 40%, increase the global EBF rate to at least 50%, and reduce and maintain childhood wasting to less than 5% by the year 2025, respectively ^[1]. However, there are varied reports on how many countries in LMICs are on track to meet the WHO GNT. For example, a recent study showed that only three African countries would meet the GNT for EBF ^[2].

o improve global infant and young child feeding, the WHO recently endorsed a set of Global Nutrition Targets (WHO GNT, including Goals 1, 5, and 6). These goals aim to reduce the number of stunted children by 40%, increase the global EBF rate to at least 50%, and reduce and maintain childhood wasting to less than 5% by the year 2025, respectively [15]. However, there are varied reports on how many countries in LMICs are on track to meet the WHO GNT. For example, a recent study showed that only three African countries would meet the GNT for EBF [16].

In India, a recent study showed that the prevalence of EBF was 55% at the national level ^[3], higher than the WHO GNT for EBF. While this is commendable, improving EBF prevalence and other breastfeeding practices is also essential to further reduce the burden of diarrhea-related morbidity ^[4] and stunting in India ^[5]. Notably, recent research indicates that the prevalence of inappropriate complementary feeding is high in India ^[6]. The prevalence of introduction of solid, semi-solid, or soft foods (complementary foods) among infants aged 6–8 months was 42.7% nationally ^[7], while that of minimum dietary diversity was 22% at national level ^[7]. Prevalence of minimum meal frequency nationally was 35.9% ^[7] and minimum acceptable diet was 9.6% ^[7]. Inappropriate complementary feeding practices are a significant contributor to the burden of childhood underweight, stunting, and wasting in India ^[5][8][9].

In India, a recent study showed that the prevalence of EBF was 55% at the national level [17], higher than the WHO GNT for EBF. While this is commendable, improving EBF prevalence and other breastfeeding practices is also essential to further reduce the burden of diarrhea-related morbidity [2] and stunting in India [4]. Notably, recent research indicates that the prevalence of inappropriate complementary feeding is high in India [18]. The prevalence of introduction of solid, semi-solid, or soft foods (complementary foods) among infants aged 6–8 months was 42.7% nationally [19], while that of minimum dietary diversity was 22% at national level [19]. Prevalence of minimum meal frequency nationally was 35.9% [19] and minimum acceptable diet was 9.6% [19]. Inappropriate complementary feeding practices are a significant contributor to the burden of childhood underweight, stunting, and wasting in India [4,20,21].

Understanding what factors act as enablers and barriers to the broader IYCF practices across regional areas and at the national level in India is essential to improving childhood nutritional status in the country. In 2017, a systematic review conducted for India showed that complementary feeding behaviors were largely influenced by cultural practices, limited knowledge of appropriate complementary feeding practices, and low parental education ^[8]. While useful for informing policy interventions in India, the study has several limitations. Firstly, the study did not incorporate or assess what can influence other important IYCF behaviors (e.g., early initiation of breastfeeding (EIBF) or EBF). Secondly, the study did not capture recent studies that used recent nationally representative data in India. Hence, there is need for a comprehensive systematic review to incorporate newer IYCF indicators based on the newer health data to better guide the policymakers and public health researchers towards improving children’s health and their nutrition requirements. The availability of recent health data reflects current socioeconomic and health status of the community and suggests the need for up-to-date evidence on what can influence IYCF behaviors in the household and community. Finally, a lack of assessment of important IYCF behaviors using new data may be limited in informing multi-faceted approaches required to improve the nutritional needs of Indian children.

Understanding what factors act as enablers and barriers to the broader IYCF practices across regional areas and at the national level in India is essential to improving childhood nutritional status in the country. In 2017, a systematic review conducted for India showed that complementary feeding behaviors were largely influenced by cultural practices, limited knowledge of appropriate complementary feeding practices, and low parental education [20]. While useful for informing policy interventions in India, the study has several limitations. Firstly, the study did not incorporate or assess what can influence other important IYCF behaviors (e.g., early initiation of breastfeeding (EIBF) or EBF). Secondly, the study did not capture recent studies that used recent nationally representative data in India. Hence, there is need for a comprehensive systematic review to incorporate newer IYCF indicators based on the newer health data to better guide the policymakers and public health researchers towards improving children’s health and their nutrition requirements. The availability of recent health data reflects current socioeconomic and health status of the community and suggests the need for up-to-date evidence on what can influence IYCF behaviors in the household and community. Finally, a lack of assessment of important IYCF behaviors using new data may be limited in informing multi-faceted approaches required to improve the nutritional needs of Indian children.

2. Research progress

2.1. Factors Associated with EIBF

The review showed that higher socioeconomic status ^[10][11], higher maternal education ^{[10][12][13][14][15][16][17][18]}, maternal employment ^[19], access to media sources ^[19], term/post-term birth ^[14][15][16] ^[16][18][20], and maternal age (≥20 years) ^[14][18] were associated with EIBF. Similarly, a receipt of breastfeeding counselling ^[14][16][20], frequent ANC visits ^[13] (≥3 ^[18], ≥4 ^[12], ≥7 ^[21][19]), health facility birthing ^{[12][17][20][22]}, births assisted by health professionals ^[10], and vaginal birthing ^{[12][14][15][16][22]} were associated with EIBF. However, rural/urban residence ^[17] and caesarean birthing ^[12] were associated with delayed initiation of breastfeeding.

The review showed that higher socioeconomic status [28,29], higher maternal education [28,30,31,32,33,34,35,36], maternal employment [24], access to media sources [24], term/post-term birth [32,33,34] [34,36,37], and maternal age (≥20 years) [32,36] were associated with EIBF. Similarly, a receipt of breastfeeding counselling [32,34,37], frequent ANC visits [31] (≥3 [36], ≥4 [30], ≥7 [23,24]), health facility birthing [30,35,37,38], births assisted by health professionals [28], and vaginal birthing [30,32,33,34,38] were associated with EIBF. However, rural/urban residence [35] and caesarean birthing [30] were associated with delayed initiation of breastfeeding.

2.2. Factors Associated with EBF Less than Six Months of Age

In the review, we found that middle or higher socioeconomic status ^{[23][24][25][26]}, nuclear family ^[27][28][29], small family size ^[27][30], male children ^[3][31], female children ^[32], preterm birth ^[28], smaller babies at birth ^[29], lower birth order ^[12], maternal age ^[21][33] (20–25 years ^[20][24]), higher maternal education ^{[27][31][34][35][36][37][38]}, maternal unemployment ^[22][30], and multiparity ^[24] were associated with EBF. Similarly, low socioeconomic status ^[22], low maternal education ^[22][28], employed mothers ^[29], and primiparity ^[36] and breastfeeding counselling ^[34][39][40] were also associated with EBF. Additionally, some studies found that young maternal age (15–24 years ^[38], <20 years ^[29]), low socioeconomic status ^[38], and urban residence ^[29] were associated with low EBF. In contrast, breastfeeding counselling ^[39][41][42], registration for ANC ^[24][26], number of ANC visits (≥3 ^[43][33][36], ≥4 ^[36], ≥7 ^[33]), hospital birthing ^[12][26], access to the type of birthing assistance, and vaginal birthing ^[44][15][29] were associated with EBF.

2.2. Factors Associated with EBF Less than Six Months of Age

In the review, we found that middle or higher socioeconomic status [25,39,40,41], nuclear family [42,43,44], small family size [42,45], male children [17,46], female children [47], preterm birth [43], smaller babies at birth [44], lower birth order [30], maternal age [23,48] (20–25 years [37,39]), higher maternal education [42,46,49,50,51,52,53], maternal unemployment [38,45], and multiparity [39] were associated with EBF. Similarly, low socioeconomic status [38], low maternal education [38,43], employed mothers [44], and primiparity [51] and breastfeeding counselling [49,54,55] were also associated with EBF. Additionally, some studies found that young maternal age (15–24 years [53], <20 years [44]), low socioeconomic status [53], and urban residence [44] were associated with low EBF. In contrast, breastfeeding counselling [54,56,57], registration for ANC [39,41], number of ANC visits (≥3 [27,48,51], ≥4 [51], ≥7 [48]), hospital birthing [30,41], access to the type of birthing assistance, and vaginal birthing [26,33,44] were associated with EBF.

In contrast, factors such as high socioeconomic status ^[29][44], male children ^[31][46], early marriage of parents ^[31][46], young maternal age (≤20 years) ^[35][50], low maternal education ^[23][31][25,46], primiparity ^[35][50], employed mothers ^[29][31][44,46], less frequent ANC visits (≤4) ^[31][46], caesarean birthing ^[31][46], delayed initiation of breastfeeding ^[31][46], a lack of knowledge about EBF ^[31][46], and poor maternal counselling regarding EBF ^[31][46] were barriers to EBF. Additionally, higher socioeconomic status ^[3][44][45][17,26,58], nuclear family ^[46][59], higher birth order ^[3][17], female children ^[3][17], larger baby size at birth ^[3][17], higher maternal education ^{[3][23][37][45][47]}[17,25,52,58,60], consecutive birthing (≤24 months) ^[35][50], rural residence ^[3][29][17,44], health facility birthing ^[19][24], and birthing in summer ^[46][59] were negatively associated with EBF whereas one study Mahmood et al. ^[41][56] found no association between maternal factors and EBF.

2.3. Factors Associated with Continued Breastfeeding at One Year (12–15 Months)

Only one study by Kumar et al. [40] considered continued breastfeeding at one year, and the study showed that maternal age (21–30 years) and joint family were associated with continued breastfeeding at one year.

Only one study by Kumar et al. ^[25] considered continued breastfeeding at one year, and the study showed that maternal age (21–30 years) and joint family were associated with continued breastfeeding at one year.

2.4. Factors Associated with the Introduction of Solid, Semi-Solid, or Soft Foods, 6–8 Months

In the reviewed studies, we found that middle or high socioeconomic status ^{[6][42][45][48]}[18,57,58,61], access to media ^[19][48][24,61], male children ^[12][30], high birth order ^[6][45][18,58], high maternal education ^{[12][13][20][42][45]}[30,31,37,57,58], high parity ^[42][57], urban residence ^[6][18], frequent ANC visits ^[20][47][37,60] (≥4 ^[6][18], ≥6 ^[48][61], >7 ^[19][24]), health professional advice ^[47][60], hospital birthing ^[42][45][57,58], and vaginal birthing ^[42][57] were associated with introduction of solid, semi-solid, or soft foods.

2.5. Factors Associated with MDD, 6–23 Months

The review demonstrated that MDD was associated with higher socioeconomic status ^[6][49][18,22], media exposure ^[47][60], higher maternal education ^[6][18], woman’s autonomy over power of earnings ^[6][18], higher birth order ^[6][49][18,22], urban residence ^[49][22], and frequent ANC visits (≥4) ^[6][18]. Low socioeconomic status ^[48][61], low maternal education ^[48][61], lower media exposure ^[48][61], and fewer ANC visits (<6 to none) ^[48][61] were associated with inadequate MDD.

2.6. Factors Associated with MMF, 6–23 Months

The review showed that MMF was associated with higher socioeconomic status [18], media exposure [60], male gender [22], higher birth order (≥2) [18], higher maternal education [18,22], woman’s autonomy over finances [18], urban residence [22], health professional-assisted births [18], and frequent ANC visits (≥4) [18]. Low socioeconomic status [61], less exposure to media [61], low maternal education [61], less power over household decision making [61], and less frequent ANC visits (<6 to none) [61] were associated with inadequate MMF.

The review showed that MMF was associated with higher socioeconomic status ^[6], media exposure ^[47], male gender ^[49], higher birth order (≥2) ^[6], higher maternal education ^[6][49], woman’s autonomy over finances ^[6], urban residence ^[49], health professional-assisted births ^[6], and frequent ANC visits (≥4) ^[6]. Low socioeconomic status ^[48], less exposure to media ^[48], low maternal education ^[48], less power over household decision making ^[48], and less frequent ANC visits (<6 to none) ^[48] were associated with inadequate MMF.

2.7. Factors Associated with MAD, 6–23 Months

The reviewed studies demonstrated that MAD was associated with richer households [18,22], male children [22], higher birth order [18,22], older maternal age (≥25 years) [18], urban residence [22], health facility birthing [18,58], and ANC visits (≥4) [18]. Lower socioeconomic status [61], low maternal education [61], less exposure to media [61], less power over household decision making [61], and less frequent ANC visits (<6 to none) [61] were associated with inadequate MAD.

The reviewed studies demonstrated that MAD was associated with richer households ^[6][49], male children ^[49], higher birth order ^[6][49], older maternal age (≥25 years) ^[6], urban residence ^[49], health facility birthing ^[6][45], and ANC visits (≥4) ^[6]. Lower socioeconomic status ^[48], low maternal education ^[48], less exposure to media ^[48], less power over household decision making ^[48], and less frequent ANC visits (<6 to none) ^[48] were associated with inadequate MAD.

2.8. Factors Associated with Continued Breastfeeding at Two Years (20–23 Months)

In the reviewed studies, we found that high socioeconomic status [62], high maternal education [63], private hospital birthing [62], and increasing urbanicity [63] were associated with breastfeeding discontinuation before 24 months. Male children [62,64], higher birth order (≥2) [62], rural women [62,64], younger mothers (≤20 years) [64], and increasing maternal age at childbirth [62] were associated with continued breastfeeding at two years. Additionally, frequent ANC visits [62] and birthing assistance by a friend [64] were associated with continued breastfeeding at two years.

In the reviewed studies, we found that high socioeconomic status ^[50], high maternal education ^[51], private hospital birthing ^[50], and increasing urbanicity ^[51] were associated with breastfeeding discontinuation before 24 months. Male children ^[50][52], higher birth order (≥2) ^[50], rural women ^[50][52], younger mothers (≤20 years) ^[52], and increasing maternal age at childbirth ^[50] were associated with continued breastfeeding at two years. Additionally, frequent ANC visits ^[50] and birthing assistance by a friend ^[52] were associated with continued breastfeeding at two years.

2.9. Factors Associated with Predominant Breastfeeding Less than Six Months of Age

Srivastava et al. [25] demonstrated that factors associated with predominant breastfeeding included lower socioeconomic status, lower maternal and paternal education, fewer ANC visits (<3), and fewer TT vaccinations.

Srivastava et al. ^[23] demonstrated that factors associated with predominant breastfeeding included lower socioeconomic status, lower maternal and paternal education, fewer ANC visits (<3), and fewer TT vaccinations.

2.10. Factors Associated with Bottle Feeding, 0–23 Months

Patel et al. ^[19] found that the factors associated with bottle feeding included birthing assisted by non-health professionals, smaller birth size, higher socioeconomic status, higher media exposure, maternal employment, higher maternal education, and urban residence.

Patel et al. [24] found that the factors associated with bottle feeding included birthing assisted by non-health professionals, smaller birth size, higher socioeconomic status, higher media exposure, maternal employment, higher maternal education, and urban residence.