Determinants of complementary feeding practices among Nepalese children aged 6-23 months: findings from Demographic and Health Survey 2011.

BACKGROUND: The adoption of inappropriate feeding practices is one of the reasons for under nutrition in Nepal and elsewhere. The objective of this study was to describe the rate of and identify the factors associated with providing the World Health Organization (WHO) recommended infant feeding practices of minimum dietary diversity, minimum meal frequency and minimum acceptable diet in Nepal amongst young children between 6-23 months in 2011. METHODS: Data from Nepal Demographic and Health Survey (NDHS) 2011 was used. Prevalence of minimum dietary diversity, minimum meal frequency and minimum acceptable diet was obtained by using descriptive statistics. A Chi-square test (χ2) followed by multiple logistic regression analyses were used to determine the adjusted effect of potential factors on the outcome variables. RESULTS: Of the 698 children aged 6-23 months; while 535 (76.6%) received the minimum meal frequency, only 212 (30.4%) children received the minimum dietary diversity, and 185 (26.5%) received an acceptable diet. Children of older mothers (>35 years); educated mothers and fathers; and mothers from all the development regions except the Mid-western region were more likely to have been provided with the recommended dietary diversity. Children of mothers who had attended ≥4 antenatal visits and who lived in the Eastern region were more likely to provide their child with the recommended meal frequency. Children of mothers, who attended ≥ 4 antenatal visits, were educated and whose fathers had at least a secondary education were more likely to meet the recommended acceptable diet standards. CONCLUSION: Young children aged less than two years in Nepal are at risk for not meeting the WHO recommended infant feeding standards given that only about one in three children were provided with the recommended dietary diversity and acceptable diet. This finding suggests that the majority of children are at risk of under nutrition. An appropriate mix of health education and food supplements could be a feasible option for Nepal to improve the number of children who meet the recommended infant feeding guidelines, reduce under nutrition and improve the survival rates of young children.

Infant and young child feeding practices and its associated factors among mothers of under two years children in a western hilly region of Nepal.

Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. Nepal government has developed and implemented different programs to improve infant and young child feeding practice. However, the practice remains poor and is a major cause of malnutrition in Nepal. This study aims to identify infant and young child feeding practices and its associated factors among mothers of children aged less than two years in western hilly region of Nepal. A descriptive cross-sectional study was carried out among 360 mothers of under two years' children in Syangja district. A semi structural questionnaire was used. Data was entered in EpiData and analyzed using IBM SPSS version 21. Descriptive statistics were used to report the feeding practices and other independent variables. Bivariate and multivariate logistic regression model was used to establish the factors associated with infant and young child feeding practices. The prevalence of breastfeeding, timely initiation of breastfeeding, exclusive breastfeeding, timely initiation of complementary feeding, minimum dietary diversity, minimum meal frequency and minimum acceptable diet (MAD) were 95.6%, 69.2%, 47.6%, 53.3%, 61.5%, 67.3% and 49.9% respectively. Normal delivery (AOR 6.1, 95% CI 1.2-31.3) and higher maternal autonomy (AOR 5.2, 95% CI 1.8-14.6) were significantly associated with exclusive breastfeeding. Similarly, crop production and food security (AOR 3.8, 95% CI 1.9-7.7), maternal knowledge on MAD (AOR 2.5, 95% CI 1.0-6.2) and maternal autonomy (AOR 4.2, 95% CI 2.1-8.4) were significantly associated with minimum acceptable diet. Factors such as maternal education, maternal health services utilization, maternal knowledge, and maternal autonomy were associated with infant and young child feeding practices, which warrants further attention to these factors to reduce malnutrition.

Complementary feeding for infants 6 to 12 months.

Complementary feeding, also known as weaning, mixed feeding or introduction of solid foods, should begin for infants by six months of age (26 weeks) but not before 17 weeks. Breast milk or infant formula should continue during the complementary feeding period with amounts gradually reduced as the variety of foods increases. As all infants' needs are different, health care professionals have to be aware of key nutrients and foods needed at the same time as monitoring growth and understanding the needs of parents and the resources available to them.

Nutritional Aspects of Commercially Available Complementary Foods in New Zealand Supermarkets.

Optimal nutrition in early childhood fosters growth and development whilst preventing morbidity and mortality in later life. There is little research in New Zealand on commercially available complementary foods (CACFs). This cross-sectional study of the nutritional aspects and packaging of CACFs used data collected in four major supermarket chains in New Zealand in 2019 (Nutritrack). Of the 197 CACFs analysed, 43 (21.8%) were inappropriately recommended for consumption by children four months of age or older, 10 (5.1%) had added salt, and 67 (34.0%) contained free sugars. The majority (n = 136, 69.0%) contained ingredients with a sweet flavour. Relatively sweet vegetables like carrot and sweetcorn were used more often than bitter vegetables such as broccoli and spinach. The described texture of most (n = 145, 62.1%) wet 'spoonable' products was of the lowest complexity (smooth, puréed, custard). CACFs would adequately expose children to cow's milk and wheat but not to other common food allergens (cooked hen's egg, soy, fish, crustacean shellfish, peanut, and tree-nuts). If children's diets include CACFs, non-commercial meals must be offered as well in order to meet nutritional guidelines related to the introduction of common food allergens, diversity of flavours, and complex textures for infants and toddlers.

Infant Food Security in New Zealand: A Multidimensional Index Developed from Cohort Data.

Food security (FS) during infancy is associated with lifelong outcomes. New Zealand is a developed economy that reports poor childhood nutrition-related health statistics, particularly among minority children, yet has no measure of FS applicable to infancy. The objective was to develop an FS index for New Zealand infants and examine its association with demographic covariates and health outcomes. Within a large (n = 6853) nationally representative cohort, variables describing infant food consumption, breastfeeding, and maternal food-related coping methods were collected from mothers during late infancy. An FS index was derived using confirmatory factor analysis. Associations were assessed by logistic regressions and described using odds ratios (OR) and ≥95% confidence intervals (CI). Fifteen percent of the cohort was highly FS, 43% tenuously food insecure (FIS), and 16% highly food insecure (FIS). Infants from minority ethnic groups had lower odds of being food secure, as did those born to the youngest mothers, mothers who smoked, or those who lived in low-income households. FIS infants had higher odds of morbidity. Interventions to improve infant FS should focus on improving dietary quality, and should give particular consideration to minority infants. We identified that FIS shows wide ethnic and socioeconomic inequity, and is associated with poorer health. The most important driving factors of FIS included poor quality weaning diets, as well as poverty and its proxies. Any interventions to improve infant FS should focus on increasing fruit and vegetable consumption to recommended intake levels, and should give particular consideration to minority infants.

New guidelines for managing cow's milk allergy in infants.

The prevalence of allergic disease has increased markedly over the last 50 years. Food allergy usually manifests in early childhood as part of the so-called atopic march and most commonly includes one or more of the following foods: cow's milk, hen's egg, soy, peanuts and tree nuts, wheat, sesame seed, kiwi fruit and seafood. In the UK about 2% of infants develop cow's milk protein allergy (CMPA), but as many as 15% of infants present with symptoms suggestive of an adverse reaction to cow's milk protein. The diagnosis of CMPA is based on one or more of the following: a detailed clinical history, allergy test results (skin prick testing [SPT] and/or specific immunoglobulin E [IgE]) and, if required, supervised incremental milk challenges. The majority of UK primary care centres do not have access to these tests and may also be unfamiliar with the interpretation or results. In addition, they do not have the facilities for supervised food challenges. Empirical treatment is often required pending confirmation of allergy or referral to a specialist centre, but requires clear guidelines. No consensus guidelines currently exist for the diagnosis and management of CMPA in the UK. An international task force has recently published proposed guidelines for the management of CMPA. These provide separate algorithms covering the diagnosis and management of CMPA for both breast-fed and formula-fed infants and discuss the use of hypoallergenic formulae, elimination diets and diagnostic tests. Revisions and adaptations for the UK market are required and are discussed in this article.

Perspective: Novel Commercial Packaging and Devices for Complementary Feeding.

In recent years, so-called baby food pouches and other novel packaging and devices have been marketed for complementary feeding. To date, no experimental studies have been conducted to determine health and nutrition effects or the safety of baby food pouches and related feeding devices. Yet, these products hold the potential to fundamentally change the ways in which infants and children consume solid foods in infancy and early childhood. In this review, a selection of complementary feeding devices and their potential effects on breastfeeding, formula-feeding, safe and appropriate complementary feeding, and the timely transition to family foods are explored. Because manufacturers have innovated older designs of traditional feeding bottles and pacifiers for complementary feeding, perspectives on potential health effects and the safety of devices are drawn from research on feeding bottles and pacifiers. Recommendations include scaling up research on the safety, nutrition, and health impacts of commercial packaging and devices. In addition, manufacturers should ensure that devices conform to consumer product safety commission specifications and that instructions for use are in line with policies protecting pediatric dental health. Marketing of commercial devices and packaging should conform to the International Code of Marketing of Breastmilk Substitutes.

Optimal Distribution and Utilization of Donated Human Breast Milk.

BACKGROUND: The nutritional content of donated expressed breast milk (DEBM) is variable. Using DEBM to provide for the energy requirements of neonates is challenging. OBJECTIVE: The authors hypothesized that a system of DEBM energy content categorization and distribution would improve energy intake from DEBM. METHODS: We compared infants' actual cumulative energy intake with projected energy intake, had they been fed using our proposed system. Eighty-five milk samples were ranked by energy content. The bottom, middle, and top tertiles were classified as red, amber, and green energy content categories, respectively. Data on 378 feeding days from 20 babies who received this milk were analyzed. Total daily intake of DEBM was calculated in mL/kg/day and similarly ranked. Infants received red energy content milk, with DEBM intake in the bottom daily volume intake tertile; amber energy content milk, with intake in the middle daily volume intake tertile; and green energy content milk when intake reached the top daily volume intake tertile. RESULTS: Actual median cumulative energy intake from DEBM was 1612 (range, 15-11 182) kcal. Using DEBM with the minimum energy content from the 3 DEBM energy content categories, median projected cumulative intake was 1670 (range 13-11 077) kcal, which was not statistically significant ( P = .418). Statistical significance was achieved using DEBM with the median and maximum energy content from each energy content category, giving median projected cumulative intakes of 1859 kcal ( P = .0006) and 2280 kcal ( P = .0001), respectively. CONCLUSION: Cumulative energy intake from DEBM can be improved by categorizing and distributing milk according to energy content.

Reasons for Infant Feeding Decisions in Low-Income Families in Washington, DC.

BACKGROUND: Breastfeeding rates for low-income, African American infants remain low. OBJECTIVE: This study aimed to determine the barriers, support, and influences for infant feeding decisions among women enrolled in the Washington, DC, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) after revisions in the WIC package to include more food vouchers for breastfeeding mothers and their infants and improvement of in-hospital breastfeeding support. METHODS: We surveyed 100 women, using a 42-item verbally administered survey that asked about demographics, infant feeding method, and influences and support for feeding decisions. RESULTS: The majority of participants (76%) initiated breastfeeding; 31% exclusively breastfed in the hospital. Participants were more likely to breastfeed if they had some college education, were unemployed or employed full-time, had only one child, and had been breastfed themselves as infants. Barriers to prolonged breastfeeding included limited support after hospital discharge, pain, and perceived insufficient milk supply. Participants in this study had higher breastfeeding initiation and in-hospital exclusivity rates after improvement of in-hospital breastfeeding support. CONCLUSION: Clients of WIC initiated breastfeeding at a high rate but either supplemented with formula or stopped breastfeeding for reasons that could be remedied by improved prenatal education, encouragement of exclusive breastfeeding in the hospital, and more outpatient support.

Behavioral aspects of development of eating behavior and nutrition status.

Studies on the development of eating behavior in rural India indicated that mothers of young children made food choices that fit into their budgets, and were also influenced by new information. Their choices were still immersed in traditional beliefs, some of which had positive effects on nutrition. Specific childrearing behaviors influenced positive deviance in the growth and psychosocial development of infants and preschoolers. A life-cycle approach to the development of eating behavior that deciphers needs at each stage and linkages between stages is necessary. Cost-benefit needs to be considered when devising strategies for future intervention programs.

Historical review of the changing pattern of infant feeding in developing countries: the case of Malaysia, the Caribbean, Nigeria and Zaire.

Prolonged lactation and early supplementation have been traditional practices among low-income mothers in Malaysia, the Caribbean, Nigeria and Zaire. Early supplementation is still the norm but there have been some substantial changes in the types of supplement offered. Thus, except in Zaire, there is now widespread use of processed milks as supplements for very young infants. The use of processed milks began in the 1920s in Malaysia and the Caribbean, but not until the 1960s in Nigeria. Processed milks are, as yet, rarely used in Zaire. The use of processed milks has not, however, led to the abandonment of traditional paps. The latter are still given as supplements to young infants in Nigeria and to older infants in Malaysia and the Caribbean. Breast-feeding duration has declined in Malaysia and the Caribbean although initiation is almost universal. In Nigeria and Zaire most low-income mothers continue to breast-feed for at least 12 months. The changes in the types of supplements used and in breast-feeding duration are analogous to the changes observed in industrialised countries from the mid-19th century, and many of the associated factors are similar: urbanisation; female participation in the labour force; increased availability of processed milks and their promotion both by companies and the health sector; and the regimentation of breast-feeding. This review highlights the negative role played by the health sector in the past, and discusses its future role in promoting and supporting breast-feeding.

Which formula in cow's milk protein intolerance? The dietitian's dilemma.

During the last century a wide range of protein sources have been used to replace cow's milk to provide an alternative milk in the treatment of cow's milk protein intolerance. These include soya (Businco et al., 1992), ass's milk (Iacono et al., 1992), soya/beef hydrolysate (Dean et al., 1993), almonds (Moll, 1923), poppy seeds (Findelstein 1930), cereals (Wolpe & Silverstone, 1942), whey hydrolysate (Walker-Smith, Digeon & Phillips, 1989) casein hydrolysate (Walker-Smith et al., 1989) and taro (Feingold, 1942). Important factors influencing the choice of milk substitute include nutritional composition, evidence of successful use with particular reference to satisfactory growth and nutritional status, palatablility, ease of preparation, cost, availability and allergenicity.

Becoming Baby-Friendly: overcoming the issue of accepting free formula.

Although, in the current financial climate, paying for formula is a difficult step for US hospitals, demystifying the process helps. Actual formula costs may be lower than perceived costs because agreements with formula companies may list unnecessary or unused products and services. Fair market value is difficult to define, but by contacting other hospitals with Baby-Friendly status, those costs can be determined. While we do not recommend that other institutions forge ahead on the track to Baby-Friendly designation without considering the formula issue, we would encourage them to apply for the certificate of intent and begin work, even if it is not immediately clear how the hospital will pay for formula. Each of the Ten Steps takes the hospital along an important course, is never wasted effort, and increases the number of breastfeeding mothers (thereby reducing formula costs). Demonstrating a willingness to invest time and energy for the benefit of patients and the institution as a whole is valuable when requesting support for formula payment. Hospital administrators, who may make the final decision regarding formula payment, will be more willing to listen to breastfeeding advocates if they have already accomplished significant goals within the institution and have collected supporting data. The authors conclude that although for BMC not accepting free formula was the most difficult barrier to overcome on the path to Baby-Friendly designation, it was not insurmountable, and we hope other institutions will be helped by learning how we dealt with this problem.

The association of formula samples given at hospital discharge with the early duration of breastfeeding.

Conflicting results have been reported regarding the association of formula samples given at hospital discharge with breastfeeding duration. This study investigated the relationship between the distribution of formula samples and breastfeeding duration in low-income Hispanic women. A gift pack of formula was distributed randomly to 88 breastfeeding women. All women received a telephone call at one and three weeks to collect information about infant feeding. Chi-square analysis revealed no significant difference in the proportion of women exclusively breastfeeding at one week. However, fewer women were exclusively breastfeeding in the gift pack group at three weeks (p less than .004). Gift packs given to Hispanic breastfeeding women are associated with a decrease in exclusively breastfeeding during the first three weeks postpartum.

Factors influencing the duration of exclusive breastfeeding in a group of Turkish women.

This study was conducted to evaluate the influence of demographic characteristics, hospital practices, maternal psychosocial factors, and knowledge about infant feeding and breast milk on duration of breastfeeding. The mothers of 91 healthy, term infants delivered at a university hospital between June 1998 and December 1998, and first seen in the well-child unit within 10 days of delivery, participated in the study. Forty-nine (54%) infants were exclusively breastfed at 4 months of age. Cox regression analysis showed a negative association between formula supplementation during the hospital stay and duration of exclusive breastfeeding. The median age for starting non-breast milk liquids was 1 month for those who received formula in the hospital and 3 months for those who did not (P = .001). The hospital practices were more predictive of the duration of exclusive breastfeeding in this study group than mothers' knowledge of infant feeding or psychosocial factors. Thus, hospital practices should be reevaluated.

Household-level technologies to improve the availability and preparation of adequate and safe complementary foods.

Plant-based complementary foods are the main source of nutrients for many young children in developing countries. They may, however, present problems in providing nutritionally adequate and safe diets for older infants and young children. The high starch content leads to low-nutrient diets that are bulky and dense, with high levels of antinutritive factors such as phytates, tannins, lectins, and enzyme inhibitors. Phytates impair mineral bioavailability, lectins interfere with intestinal structure, and enzyme inhibitors inhibit digestive enzymes. In addition, there is often microbial contamination, which leads to diarrhea, growth-faltering, and impaired development, and the presence of chemical contaminants may lead to neurological disease and goiter. The fact that some fruits containing carotenoids are only available seasonally contributes to the vulnerability of children receiving predominantly plant-based diets. Traditional household food technologies have been used for centuries to improve the quality and safety of complementary foods. These include dehulling, peeling, soaking, germination, fermentation, and drying. While modern communities tend to reject these technologies in favor of more convenient fast-food preparations, there is now a resurgence of interest in older technologies as a possible means of improving the quality and safety of complementary foods when the basic diet cannot be changed for economic reasons. This paper describes the biology, safety, practicability, and acceptability of these traditional processes at the household or community level, as well as the gaps in research, so that more effective policies and programs can be implemented to improve the quality and safety of complementary foods.

Macrolevel approaches to improve the availability of complementary foods.

Large numbers of infants and young children suffer from the short- and long-term health effects of poor breastfeeding and complementary feeding practices. Strategies to improve the availability of and access to low-cost fortified complementary foods can play an important corresponding role to that of behavior change in improving nutritional status of young children. However, the nutritional quality of complementary foods used in publicly funded programs is not always optimal, and such programs are costly and reach only a tiny fraction of those who could benefit. To broadly reach the target population, such foods need to be commercially available at affordable prices and promoted in a way that generates demand for their purchase. A sensible long-term policy for the promotion of low-cost fortified complementary foods calls for attention to their nutritional formulations and cost, the economics of production, and the legislative, regulatory, and competitive framework in which marketing occurs. This paper provides information on how to improve the nutritional formulations of fortified complementary foods and outlines the necessary conditions for a market approach to their production and promotion.

Bottle feeding and ideology in colonial Malaya: the production of change.

Considerable attention has been paid to the correlation between high infant morbidity and mortality rates and the increased incidence of bottle feeding. The shift from prolonged breast feeding to a mixed regime or the exclusive use of sweetened condensed milk or infant formula has been related to the promotional activities of milk companies, and typically has been presented as a relatively recent development in Third World countries. However, the marketing of tinned and powdered milk only partially explains the increased use of these products. In colonial Malaya, condensed milk was marketed from the late 19th century. Infant formula was available from the turn of the century and was widely advertised, first in the English-language press and later also in the vernacular presses. At the same time, other social and cultural factors served to discourage breast feeding. There were changes in ideas regarding ideal body weight for both women and infants, and regarding infant care and diet; these ideas were presented in the mass media. In addition, maternal and child health clinics, established in the 1920s to reduce the high infant mortality rate, both propagated popular beliefs about infant weight and supplied milk and educated women to artificially feed their infants. Industry, the media, and health services all promoted, if not always intentionally, bottle feeding rather than breast feeding. Bottle feeding as an ideal, if not a reality, was thus well established before the intensive promotion of milk products by multinational corporations that followed the political independence of the colony.

Pattern of formula feeding in the latter part of infancy: a preliminary survey.

The pattern of formula feeding in 111 infants between 5 and 12 months of age was studied by the use of a simple questionnaire filled in by the clinician during a consultation. Their growth pattern was noted by perusal of the weight-for-age chart, which forms part of the child health record sheet. Of the infants studied, 39 (35%) were on a starter formula, 39 (35%) were on an unmodified formula, 33 (30%) were on a special follow-on formula. The change over from starter formula to an unmodified or special follow-on formula was done at 6.9 months, which is later than recommended. Only 2 infants were on Lakspray, the cheapest unmodified formula. Growth faltering was seen in 70% of the infants studied and was apparently commoner in those on unmodified formula. Reconstitution of milk powder with water was done erroneously by 50% of the mothers, errors being most common in those using unmodified formula. Not providing a scoop inside the pack, and complex mixing instructions were the causes of error in reconstitution.

Maternal AZT programs at the starting gate.

AIDS: The Joint United Nations Programme on HIV/AIDS (UNAIDS) is excited about the programs that developing countries are implementing to reduce mother-to-child HIV transmission. The countries interested in launching pilot projects include Zimbabwe, South Africa, and Chile. The interventions will include short-course AZT regimens and alternatives to breast feeding. Rapid testing will probably replace the existing systems to ensure that HIV-positive pregnant women are treated quickly. Glaxo-Wellcome, the manufacturer of AZT, promises to provide AZT at discounts of 50 to 75 percent. Formula makers are expected to follow suit, although there are no firm programs underway. Advocates of breast feeding were worried that formula feeding would undermine their worldwide efforts to improve children's nutrition. Now they are softening their opposition to formula feeding, due to the HIV risk associated with breast feeding.^ieng