Barriers to appropriate complementary feeding and the use of ultra-processed foods: A formative qualitative study from rural Oromia, Ethiopia.

Children's consumption of ultra-processed foods (UPF) is increasing in Ethiopia, but relatively little is known about the specific feeding practices that underlie this pattern. The objective of this study was to explore patterns of consumption of UPF by infants and young children within a broader context of inappropriate complementary feeding practices in extremely poor households in rural Oromia, Eastern Ethiopia. A formative qualitative study was conducted using semistructured interview questionnaires developed drawing on a socioecological model. A total of 16 focus group discussions with mothers (45 respondents), fathers (21 respondents) and grandmothers (23 respondents) of children aged 6-23 months in households that were beneficiaries of the Productive Safety Net Program were conducted, along with four key informant interviews with health workers. Qualitative transcripts were complemented with field notes before qualitative content analysis was applied. The key findings suggest that UPF were widely provided to infants and young children as part of a pattern of suboptimal complementary feeding, including both early and late initiation of complementary foods. In particular, UPF (including juice, biscuits and lipid-based nutrient supplements) were diluted with or dissolved in water and fed to infants via bottle, often before the recommended age of initiation of 6 months. Mothers and caregivers reported that they perceived the products to be affordably priced and packaged, ready to use and convenient given their time constraints. The level of consumption of UPF and its effects on infant and young child feeding feeding practices and children's nutritional status in rural Ethiopia should be further explored.

Prevalence of undernutrition and associated factors among children aged 6-23 months: a cross-sectional analysis from South-East Ethiopia.

To meet the 2030 goal to end all types of malnutrition, thoroughly investigating and addressing context-specific factors of undernutrition is crucial. Therefore, this study assessed the prevalence of undernutrition and associated factors among children aged 6-23 months in South-East Ethiopia. A community-based cross-sectional study was conducted on 580 randomly sampled mother-child pairs in February 2022. Socio-demographic, dietary intake, household food security (HFS), maternal knowledge and practices of child feeding, and the child's weight and height data were collected. A multivariable logistic regression analysis was done. The prevalence of stunted, wasted, and underweight children was 32⋅1, 7, and 9 %, respectively. Being male (AOR = 1⋅75), not using the growth monitoring and promotion (GMP) service (AOR = 1⋅50), household food insecurity (HFI) (AOR = 1⋅67), lack of improved water (AOR = 2⋅26), and bottle-feeding (AOR = 1⋅54) were significantly associated with stunting. Being male (AOR = 3⋅02), having low maternal knowledge on child-feeding practices (AOR = 3⋅89), not listening to the radio/television (AOR = 3⋅69), having a history of fever (AOR = 3⋅39), bottle-feeding (AOR = 3⋅58), and HFI (AOR = 3⋅77) were significantly predicted wasting. Being male (AOR = 3⋅44), not using GMP service (AOR = 2⋅00), having a history of fever (AOR = 4⋅24), lack of knowledge on optimal breastfeeding duration (AOR = 3⋅58), low maternal knowledge on child feeding (AOR = 2⋅21), HFI (AOR = 2⋅04), and lack of improved water (AOR = 3⋅00) showed significant association with underweight. In conclusion, stunting is alarmingly common while wasting and underweight are sub-optimal. Prevention of infectious disease, providing basic education for fathers, ensuring HFS; enhancing media access, maternal knowledge about IYCFP and improving water access; and GMP service utilisation are crucial to improve child nutrition.

Determinants of stunting in children aged between 6-23 months in Musanze region, Rwanda.

Under-nutrition causes approximately half of all deaths in young children every year globally which is exacerbated by the multiple malnutrition burden. Infant and young child feeding practices pose immediate effects on the nutrition status of under 2 years aged children and greatly influence the survival of a child. This study aimed at determining the implication of the infant and young child feeding practices in evaluating stunting in young children among other stunting risk factors. Analytical cross-section study was carried out in Musanze, a district of Rwanda and involved 241 mothers having children aged between 6 and 23 months. Data was collected using a validated semi-structured questionnaire with observations and check list guides. Chi-square test and logistic regressions were used to determine the associations and risk factors of various variables. The results show that minimum meal frequency (MMF) was attained at 83% rate, minimum dietary diversity (MDD) at 57%, minimum acceptable diet (MAD) at 53% with consumption of iron rich foods at 29%. Stunting prevalence was 28%. The MAD had a significant (p = 0.021) association with height-for-age Z-score of a child and was found to be the stunting's predictor. The child's sex, consumption of animal sourced foods, child underweight status and income type were revealed as other stunting risk factors. A holistic approach that promotes infant and young child feeding practices and complementary feeding in particular can contribute to the alleviation of the stunting burden in Rwanda. Further, other associated factors that influence child nutrition status should be taken into consideration by the policy decision makers and development partners when developing food and nutrition sensitive programs and interventions.

Prevalence of Sugar-Sweetened Food Consumption in Rural Bangladeshi Children Aged 6-24 Months.

BACKGROUND: While the prevalence of undernutrition in children has decreased in many low- and middle-income countries since the 1990s, prevalences of overweight and obesity have increased. Frequent consumption of sugar-sweetened food might have contributed to this change, although very little is known about sugar-sweetened food consumption in early life. OBJECTIVES: The objective of this study was to explore the associations between individual, household, and maternal factors and the prevalence of sugar-sweetened food consumption in 6- to 24-month-old children in Bangladesh. METHODS: Multistage sampling was used to select households with children aged 6-24 months in rural Chatmohar, a subdistrict of Bangladesh (n = 1635). Research assistants conducted a 24-hour qualitative dietary recall questionnaire with the enrolled child's primary caregiver to measure maternal and child dietary patterns. We examined factors associated with the prevalence of child sugar-sweetened food consumption with multivariate logistic regression models. We conducted tests of heterogeneity to explore differential associations between the child sugar-sweetened food consumption prevalence and household income by maternal nutrition knowledge and wealth. RESULTS: Primary caregivers reported that 62% of toddlers had consumed sugar-sweetened food in the past 24 hours. A higher prevalence of child sugar-sweetened food consumption was associated with both a higher dietary diversity score (OR, 1.19; 95% CI, 1.09-1.29) and a higher prevalence of maternal sugar-sweetened food consumption (OR, 2.54; 95% CI, 1.97-3.28). At higher levels of maternal nutrition knowledge and wealth, more household income was associated with a lower prevalence of child sugar-sweetened food consumption. CONCLUSIONS: Almost two-thirds of 6- to 24-month-old children in rural Chatmohar, Bangladesh, had consumed sugar-sweetened food in the last day. This is a high and concerning prevalence, and the associated factors identified in this study should be investigated further to identify potential areas of intervention to decrease the prevalence of child sugar consumption in Bangladesh.

Addressing child undernutrition in Tanzania with the ASTUTE program.

BACKGROUND: Optimal infant and young child feeding practices (IYCFP) reduce childhood stunting and are associated with additional health benefits. In Tanzania, IYCFP are far from optimal where 32% of children under the age of 5 years are stunted. The purpose of this study was to examine whether behavior change communication focused on reducing child undernutrition was associated with improved IYCFP in Tanzania. METHODS: A cross-sectional survey was administered to approximately 10,000 households with children under the age of 2 at baseline and endline. Bivariate analyses and logistic regression was used to examine the relationship between exposure to behavior change communication and timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, timely complementary feeding (CF), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). RESULTS: Mothers who heard a radio spot about IYCFP were more likely than mothers who had not heard a radio spot about IYCFP to begin complementary foods at six months. Their children were also more likely to achieve MMF, MDD, and MAD with odds ratios of 2.227 (p = 0.0061), 1.222 (p = 0.0454), 1.618 (p = < .0001), and 1.511 (p = 0.0002), respectively. Mothers who saw a TV spot about IYCFP were more likely to have greater odds of knowing when to begin complementary feeding, feeding their child a minimally diverse diet (4 food groups or more), and serving a minimum acceptable diet with odds ratios of 1.335 (p = 0.0081), 1.360 (p = 0.0003), and 1.268 (p = 0.0156), respectively. CONCLUSION: Exposure to behavior change communication in Tanzania was generally associated with some increased knowledge of optimal IYCFP as well as practicing IYCF behaviors. Behavior change communication planners and implementers may want to consider conducting similar campaigns as an important component of behavior change to reduce undernutrition and poor health outcomes in developing settings.

Levels of dietary diversity and its associated factors among children aged 6-23 months in West Shoa, Ethiopia: a comparative cross-sectional study.

Dietary diversity is one of the eight core indicators of infant and young child feeding (IYCF) practices. It is also a proxy for nutrient adequacy of the diet of individuals. There are minimal studies showing the level of dietary practice in urban and rural settings comparably. Hence, the present study intended to assess and compare differences in the level of dietary diversity and its contributing factors in urban and rural settings of the West Shoa zone of Oromia, Ethiopia. A community-based comparative cross-sectional study was conducted among 674 pairs of mothers/caregivers and children aged 6-23 months using a multistage sampling technique. Data were analysed and descriptive summaries were presented with tables, charts and graphs. A linear regression analysis was used to identify factors that were associated with the level of dietary diversity. The dietary diversity score (DDS) was 26⋅1 % (95 % CI 22⋅8, 29⋅5) both in urban and rural (P < 0⋅001), and also the minimum meal frequency was 56⋅5 % (95 % CI 52⋅7, 60⋅2) (P < 0⋅038). Child from merchant mother, own production of foods at the household level and frequent advice of IYCF practices during Post natal care (PNC) visit in urban residents, maternal secondary educational level, living with caregiver only, having a merchant father, advice of IYCF practice during PNC visit and utilisation of horse as a means of transportation in rural were positively associated with the level of dietary diversity. Generally, infant and young children who received the recommended dietary diversity and the minimum meal frequency were low in the study area both in the urban and rural settings.

Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia.

This study aimed to explore variations in Infant and Young Child Feeding (IYCF) practices between different South Asian Countries (SACs) and within their sociodemographic characteristics including place of residence, mother age, mother education, child sex, and wealth quintiles within the SACs. We extracted 0-23 months age children's data from the nationally representative survey of Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. Among all SACs, the early initiation of breastfeeding (EIBF) practice was 45.4% with the highest prevalence in the Maldives (68.2%) and the lowest prevalence in Pakistan (20.8%). Exclusive breastfeeding (EBF) practice was 53.9% with the highest prevalence in Nepal (67%) and the lowest prevalence in Afghanistan (42%). Only 13% of children had a minimum acceptable diet (MAD), with the highest prevalence in the Maldives (52%) and the lowest prevalence in India (11%). We found higher IYCF practices among the mothers with secondary or higher levels of education (EIBF: 47.0% vs. 43.6%; EBF: 55.5% vs. 52.0%; MAD: 15.3% vs. 10.0%), urban mothers (MAD: 15.6% vs. 11.8%), and mothers from the richest households (MAD: 17.6% vs. 8.6%) compared to the mothers with no formal education or below secondary level education, rural mothers and mothers from the poorest households, respectively. Mothers from the poorest households had better EIBF, EBF, and continued breastfeeding at 1-year (CBF) practices compared to the mothers from the richest households (EIBF: 44.2% vs. 40.7%; EBF: 54.8% vs. 53.0%; CBF: 86.3% vs. 77.8%). Poor IYCF practices were most prevalent in Afghanistan, Pakistan, and India.

Four-Year Effects of a 2-Year Nutrition and Gender Sensitive Agricultural Program on Women's Nutritional Status, Knowledge, and Empowerment in Rural Burkina Faso.

BACKGROUND: Little is known about the sustained effects of nutrition- and gender-sensitive agricultural programs (NSAPs) after they end. OBJECTIVES: To examine the 4-year effects (2010-2014) of a 2-year NSAP (2010-2012) on women's outcomes in rural Burkina Faso. METHODS: We used baseline (2010) and endline (2012) data from a cluster-randomized controlled trial of Helen Keller International's Enhanced Homestead Food Production (EHFP) program and baseline (2014) data from a new program. We included 134 women: 82 who participated in the 2-year EHFP program (treatment) and 52 who did not (control). We examined program (2010-2012), post-program (2012-2014), and overall 4-year effects (2010-2014) using difference-in-difference analysis (DID). RESULTS: We found significant positive program effects (2010-2012) on women's underweight prevalence (DID: 16.44 percentage points [pp]; P = .09) and on women's knowledge about appropriate age to introduce liquids (DID: 28.40 pp; P = .01). Although there were no significant postprogram effects (2012-2014), differences found in 2012 between the treatment and control group were sustained resulting in an overall 4-year (2010-2014) reduction in women's underweight prevalence (DID: 18.26 pp; P = .02) and an improvement in women's knowledge about appropriate age to introduce liquids (DID: 31.29 pp; P = .02). We observed no postprogram or overall 4-year effects on women's knowledge of child feeding and handwashing practices or women's empowerment. CONCLUSIONS: Nutrition- and gender-sensitive agricultural programs demonstrate potential for sustained improvements in women's nutritional status and nutritional knowledge. Postprogram assessments of NSAPs should be embedded in program evaluations to help further understand the potential of NSAPs to generate sustainable impacts on women's outcomes.

Factors Associated With Pre-Lacteal Feeding Practices Among Mothers Having Children Aged 0-36 Months in Bangladesh: Evidence From Bangladesh Demographic and Health Survey 2017-18.

Despite being a known barrier to optimal breast-feeding indicators, the practice of Pre-lacteal Feeding (PLF) remains a key challenge in Bangladesh. This study examines the prevalence and underlying factors associated with PLF, for which data from a weighted sample of 4982 Bangladeshi mothers with children aged 0 to 36 months from the 2017-18 Bangladesh Demographic and Health Survey was used. Step-by-step multivariate logistic regression was performed to identify the association of significant determinants of PLF practices. Nearly 29% newborns received PLF before breastmilk and timely initiation of breastfeeding did not happen in case of 20.5% babies. The odds of PLF were significantly higher among the inhabitants of Dhaka division compared to other regions. In addition, birth-related factors such as optimal ANC visits (P < .01), home delivery (P < .01) and delivered by cesarean section (P < .01) showed significantly higher odds of introducing PLF to the newborns. Our results demonstrated the need for developing targeted policies and actions to prevent such practices of PLF in order to improve optimal breastfeeding behavior in Bangladesh.

Influence of gender and parental migration on IYCF practices in 6-23-month-old tribal children in Banswara district, India: findings from the cross-sectional PANChSHEEEL study.

BACKGROUND: The interdisciplinary Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages (PANChSHEEEL) study used a participatory approach to develop locally-feasible and tailored solutions to optimise Infant and Young Child Feeding (IYCF) practices at an individual, household, community, and environmental level. This paper aims to evaluate the influence of gender; migration; and Health, Education, Engineering and Environmental (HEEE) factors on IYCF practices, with the primary outcomes being three key complementary-feeding practices of Minimum Dietary Diversity (MDD), Minimum Meal Frequency (MMF) and Minimum Acceptable Diet (MAD). METHODS: A cross-sectional survey of 325 households with children aged 6-23 months was conducted in nine purposively selected villages in two blocks of Banswara district, Rajasthan, India. A survey tool was developed, translated into the local language, pre-tested, and administered in a gender-sensitive manner. Data-collection processes were standardized to ensure quality measures. Association of the primary outcome with 27 variables was tested using a Chi-square test (Mantel-Haenszel method); backward stepwise regression analysis was conducted to assess the impact of effect modifiers (gender, parental migration). RESULTS: Half of the surveyed children were of each gender, and fathers from half of the households were found to have migrated within the previous year to search for additional income. Parental literacy ranged from 60 to 70%. More than half of the households had access to milk-producing animals. Consumption of each of the seven food groups, eggs (4.7% vs 0.7%; p < 0.02), MDD (10.5% vs 3.2%; p < 0.02) and MAD (9.4% vs 2.6%; p < 0.02) were higher for boys than for girls. After controlling for contextual factors, a male child was 4.1 times more likely to get a diet with MDD and 3.8 times more likely to get a diet with MAD. A child from a non-migrant household was 2.0-2.1 times more likely to get a diet with MDD and MAD as compared to a child from a migrant household. However, this association was not found to be statistically significant after regression. Presence of milk-producing animals in households and consumption of milk/milk products by children in the previous 24 h were the other two strong predictors of MDD and MAD, although access to animal milk in the house did not translate to an increase in consumption of milk/milk products by a child. CONCLUSION: Gender discrimination in diet diversity and complementary-feeding practices starts early in childhood with boys having a distinct advantage over girls. In the case of parental migration, further research is required to establish if it has an adverse impact on feeding practices. Emphasis needs to be given to gender issues and other contextual factors when developing strategies to optimise complementary feeding practices. TRIAL REGISTRATION: With UCL ethics [Ethics ID 4032/002] in United Kingdom and with Sigma IRB [10,025/IRB/D/17-18] in India.

Determinants of Exclusive Breastfeeding Practices Among Mothers of Infants Less Than Six Months Attending an Immunization Clinic in Southwestern Nigeria.

Background Despite being a cost-effective means of improving the childhood health indices, exclusive breastfeeding (EBF) remains low in the low middle-income countries. Hence, we evaluated the determinants of EBF among mothers of infants less than six months in Southwestern Nigeria. Methods This was a cross-sectional descriptive study that involved 271 mothers of infants aged less than six months attending the immunization clinic of the Bowen University Teaching Hospital, Ogbomoso, Nigeria. Pretested semi-structured questionnaires were used to get relevant information from the mothers who were recruited using convenience sampling method. Descriptive statistics was carried out while chi square test and binary logistic regression were used for inferential statistics. Results The mean age (±SD) of the respondents was 30.4 ± 5.0 years. The EBF rate in this study was 46.1% (125/271); 40.6% of mothers breastfed their infants within an hour of birth, with most (91.1%) breastfeeding their babies on demand. Factors associated with EBF included mothers' age > 30 years (OR 2.080, 95% CI 1.274-3.395). After controlling for potential confounders, family size > 4, (adjusted OR 2.053, 95% CI 1.120-3.762) and having vaginal delivery (adjusted OR 2.769, 95% CI 1.585-4.829) were the significant determinants of EBF practices among the study participants. Conclusion EBF practice was average in the studied population. Family size >4 and vaginal delivery were the determinants of EBF. There is a need to sustain the promotion of appropriate breastfeeding practices.

Dietary Variation among Children Meeting and Not Meeting Minimum Dietary Diversity: An Empirical Investigation of Food Group Consumption Patterns among 73,036 Children in India.

BACKGROUND: Minimum Dietary Diversity (MDD) is a widely used indicator of adequate dietary micronutrient density for children 6-23 mo old. MDD food-group data remain underutilized, despite their potential for further informing nutrition programs and policies. OBJECTIVES: We aimed to describe the diets of children meeting MDD and not meeting MDD in India using food group data, nationally and subnationally. METHODS: Food group data for children 6-23 mo old (n = 73,036) from the 2015-16 National Family Health Survey in India were analyzed. Per WHO standards, children consuming ≥5 of the following food groups in the past day or night met MDD: breast milk; grains, roots, or tubers; legumes or nuts; dairy; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Children not meeting MDD consumed <5 food groups. We analyzed the number and types of foods consumed by children meeting MDD and not meeting MDD at the national and subnational geographic levels. RESULTS: Nationally, children not meeting MDD most often consumed breast milk (84.5%), grains, roots, and tubers (62.0%), and/or dairy (42.9%). Children meeting MDD most often consumed grains, roots, and tubers (97.6%), vitamin A-rich fruits and vegetables (93.8%), breast milk (84.1%), dairy (82.1%), other fruits and vegetables (79.5%), and/or eggs (56.5%). For children not meeting MDD, district-level dairy consumption varied the most (6.4%-79.9%), whereas flesh foods consumption varied the least (0.0%-43.8%). For children meeting MDD, district-level egg consumption varied the most (0.0%-100.0%), whereas grains, roots, and tubers consumption varied the least (66.8%-100.0%). CONCLUSIONS: Children not meeting MDD had low fruit, vegetable, and protein-rich food consumption. Many children meeting MDD also had low protein-rich food consumption. Examining the number and types of foods consumed highlights priorities for children experiencing the greatest dietary deprivation, providing valuable complementary information to MDD.

Tubaramure, a Food-Assisted Maternal and Child Health and Nutrition Program in Burundi, Increased Household Food Security and Energy and Micronutrient Consumption, and Maternal and Child Dietary Diversity: A Cluster-Randomized Controlled Trial.

BACKGROUND: Food-assisted maternal and child health and nutrition programs are a widely used approach to address undernutrition. Little is known about the effects of these programs' combined household and individual food rations on household and individual food consumption. Tubaramure in Burundi targeted women and children during the first 1000 d of life, and included: 1) food rations (corn-soy blend and micronutrient-fortified vegetable oil); 2) health services strengthening and promotion of their use; and 3) behavior change communication on nutrition, hygiene, and health practices. OBJECTIVES: The objectives were: 1) to assess Tubaramure's impact on household food consumption and food security, maternal dietary diversity, and infant and young child feeding practices; 2) to explore the role of the food rations; and 3) assess 6-8 mo impacts around 8 mo after the end of the program. METHODS: We used a 4-arm cluster-randomized controlled repeated cross-sectional design (11,906 observations). The treatment arms received the same food ration but differed in the ration timing and duration: 1) the first 1000 d; 2) from pregnancy through 17.9 mo of age; or 3) from birth through 23.9 mo of age. RESULTS: Tubaramure significantly (P < 0.05) improved the percentage of food secure households [from 4.5 to 7.3 percentage points (pp)], and increased household energy consumption (from 17% to 20%) and micronutrient consumption. The program had a positive effect on maternal dietary diversity (+0.4 food groups, P < 0.05) and increased the proportion of children aged 6-23.9 mo consuming ≥4 food groups (from 8.0 to 9.6 pp, P < 0.05). The effects on many outcomes were attributable to the food rations. Postprogram effects (P < 0.05) were found on household food security, maternal dietary diversity, and younger sibling's complementary feeding practices. CONCLUSIONS: Programs such as Tubaramure have the potential to improve food security and household and individual energy and micronutrient consumption in severely resource-constrained populations, as seen in rural Burundi. This trial was registered at clinicaltrials.gov as NCT01072279.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program.

BACKGROUND: The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze. OBJECTIVES: We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program. METHODS: We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions. RESULTS: Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions. CONCLUSIONS: Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

Progress and inequalities in infant and young child feeding practices in India between 2006 and 2016.

Limited evidence exists on socio-economic status (SES) inequalities in infant and young child feeding (IYCF) in India. We examine trends and changes in inequalities for IYCF practices over 2006-2016 and identify factors that may explain differences in IYCF across SES groups. We use data from the 2015-2016 and 2005-2006 National Family Health Surveys (n = 112,133 children < 24 months). We constructed SES quintiles (Q) and assessed inequalities using concentration and slope indices. We applied path analyses to examine the relationship between SES inequalities, intermediate determinants, and IYCF. Breastfeeding improved significantly over 2006-2016: from 23% to 42% for early initiation of breastfeeding (EIBF) and 46% to 55% for exclusive breastfeeding (EBF). Minimum dietary diversity (MDD) improved modestly (15% to 21%), but adequate diet did not change (~9%). Large SES gaps (Q5-Q1) were found for EIBF (8-17%) and EBF (-15% to -10%) in 2006; these gaps closed in 2016. The most inequitable practices in 2006 were MDD and iron-rich foods (Q5 ~ 2-4 times higher than Q1); these gaps narrowed in 2016, but levels are low across SES groups. Factors along the path from SES inequalities to IYCF practices included health and nutrition services, information access, maternal education, number of children < 5 years, and urban/rural residence. The improvements in breastfeeding and narrowing of equity gaps in IYCF practices in India are significant achievements. However, ensuring the health and well-being of India's large birth cohort will require more efforts to further improve breastfeeding, and concerted actions to address all aspects of complementary feeding across SES quintiles.

Conflict or congruence? Maternal and infant-centric factors associated with shorter exclusive breastfeeding durations among the Tsimane.

Six months of exclusive breastfeeding (EBF) is considered optimal for infant health, though globally most infants begin complementary feeding (CF) earlier-including among populations that practice prolonged breastfeeding. Two frameworks for understanding patterns of early CF emerge in the literature. In the first, maternal and infant needs trade-off, as "maternal-centric" factors-related to time and energy demands, reproductive investment, cultural influences, and structural barriers- favor supplanting breastfeeding with earlier and increased CF. A second framework considers that "infant-centric" factors-related to infant energetic needs-favor CF before six months to supplement breastfeeding. We apply these two frameworks in examining early CF among the Tsimane-a high-fertility, high-mortality, forager-horticulturalist population residing in the Bolivian Amazon. Data were collected from a mixed-longitudinal sample of 161 Tsimane mother-infant pairs from August 2012-April 2013. Tsimane mothers generally reported introducing CF because of perceived infant needs. However, CF is introduced with continued intensive breastfeeding, and generally coupled with premastication. Risks of earlier CF relative to the minimum hazard (estimated at 5 births) were elevated for lower and higher parity mothers, but were significantly greater only after 9 births. Seventeen percent of mothers reported introducing CF because of low milk supply. Introducing CF because of low milk was most common from 0 to 3 months of age and among higher parity mothers, which may reflect physiological constraints. Maternal reproductive trade-offs and perceived infant needs may help explain the low prevalence of EBF to six months among other populations in which breastfeeding is not structurally or culturally constrained.

Nutrition education linked to agricultural interventions improved child dietary diversity in rural Cambodia.

Poor infant and young child feeding (IYCF) practices are major determinants of chronic malnutrition. The main objective of this study was to assess the impact of a nutrition education (NE) programme aimed at promoting improved IYCF behaviours in combination with an agriculture intervention on children's dietary diversity and nutritional status. From 2012 to 2014, a cluster randomised trial was rolled out in Cambodia in the context of an agriculture and nutrition project of the FAO of the UN. The cross-sectional baseline study was carried out in sixteen pre-selected communes in 2012. Restricted randomisation allotted the communes to either intervention (NE and agriculture intervention) or comparison arms (agriculture intervention only). The impact survey was conducted as a census in all FAO project villages in 2014. Caregivers of children aged 0-23 months were interviewed using standardised questions on socio-economic status and dietary diversity (24-h recall). Anthropometric measurements were taken. A difference-in-differences model was applied. The sample comprised 743 households with children ≥6 months of age at baseline and 921 at impact. After 1 year of NE, 69 % of the intervention households reported to have participated in the NE. Estimated mean child dietary diversity was significantly different at impact between comparison and intervention (3·6 and 3·9, respectively). In particular, the consumption of pro-vitamin A-rich foods and other fruits and vegetables increased. No treatment effects on height-for-age Z-scores could be shown. NE led to improvements in children's diets. For effects on growth, it is assumed that longer NE activities are required to achieve sustainable behaviour change of age-appropriate infant feeding.

Using Positive Deviance to Understand the Uptake of Optimal Infant and Young Child Feeding Practices by Mothers in an Urban Slum of Mumbai.

Objectives Positive deviance research seeks out well-nourished children living in disadvantaged contexts to understand local growth-promoting behaviors. This study explored the factors that influence the uptake of infant and young child feeding behaviors among mothers. Methods Children with a height-for-age z-score (HAZ) > 0 (n = 10) or a HAZ < -2.0 (n = 12) were purposefully selected from households enrolled in a community management of acute malnutrition (CMAM) program in an urban slum of Mumbai, India. Qualitative methods were employed by means of semi-structured key informant interviews with positive and non-positive deviant mothers. Eligibility was restricted to households with limited resources and more than one child. A 24-h dietary recall and anthropometric measurements were taken for the index child. An observation checklist assessed household hygiene. Data analysis was based on the Grounded Theory of qualitative research. Results Positive deviant mothers (those with children with a HAZ > 0) largely exhibited optimal infant and young child feeding practices explained by maternal information seeking behaviors; mothers acknowledging the importance of maternal health; and social support. The relationship between mother and health worker seemed to influence how well they listened to the health workers' recommendations. Across all households, the daily consumption of high-energy, processed foods was apparent. Conclusions Practical considerations include exploring how to tailor CMAM programs to include social support and counseling training for health workers to engage more closely with mothers; exploring the feasibility of a women's social group for mothers to share information on child rearing; and teaching mothers about healthy eating and the link between nutrition and health.

Association between women's empowerment and infant and child feeding practices in sub-Saharan Africa: an analysis of Demographic and Health Surveys.

OBJECTIVE: To explore the relationship between women's empowerment and WHO recommended infant and young child feeding (IYCF) practices in sub-Saharan Africa. DESIGN: Analysis was conducted using data from ten Demographic and Health Surveys between 2010 and 2013. Women's empowerment was assessed by nine standard items covering three dimensions: economic, socio-familial and legal empowerment. Three core IYCF practices examined were minimum dietary diversity, minimum meal frequency and minimum acceptable diet. Separate multivariable logistic regression models were applied for the IYCF practices on dimensional and overall empowerment in each country. SETTING: Benin, Burkina Faso, Ethiopia, Mali, Niger, Nigeria, Rwanda, Sierra Leone, Uganda and Zimbabwe. SUBJECTS: Youngest singleton children aged 6-23 months and their mothers (n 15 153). RESULTS: Less than 35 %, 60 % and 18 % of children 6-23 months of age met the criterion of minimum dietary diversity, minimum meal frequency and minimum acceptable diet, respectively. In general, likelihood of meeting the recommended IYCF criteria was positively associated with the economic dimension of women's empowerment. Socio-familial empowerment was negatively associated with the three feeding criteria, except in Zimbabwe. The legal dimension of empowerment did not show any clear pattern in the associations. Greater overall empowerment of women was consistently and positively associated with multiple IYCF practices in Mali, Rwanda and Sierra Leone. However, consistent negative relationships were found in Benin and Niger. Null or mixed results were observed in the remaining countries. CONCLUSIONS: The importance of women's empowerment for IYCF practices needs to be discussed by context and by dimension of empowerment.

Preventative lipid-based nutrient supplements (LNS) and young child feeding practices: findings from qualitative research in Haiti.

To prevent undernutrition in an urban slum in Haiti, a lipid-based nutrient supplement (LNS) was introduced through a randomised control trial. Food supplementation for young child nutrition has a long history in Haiti, but there is little empirical information regarding the effects of supplementation on young child feeding practices. One of the concerns raised by supplementation is that it may disrupt other positive feeding practices such as breastfeeding and use of other complementary foods, with negative consequences for child nutrition. We conducted 29 in-depth interviews with mother-baby pairs from the three comparison groups: control, 3-month LNS supplementation and 6-month LNS supplementation. Findings from those in the LNS groups indicated high acceptance and satisfaction with LNS and perceptions that it positively affects child health and development. LNS was integrated into and enhanced ongoing complementary feeding practices. The effects of LNS use on duration and perceived quantity of breastfeeding were variable, but generally, breastfeeding was maintained during and after the intervention. Interviews generated insights into beliefs regarding infant and young child feeding practices such as introduction and use of complementary foods, and breastfeeding duration, exclusivity and cessation. Implications for the use of LNS in public health nutrition programmes are discussed.