Association of parental level of education and child factors on length-for-age indicator among socially vulnerable children aged 6-24 months from a Brazilian state using Structural Equation Modelling.

This cross-sectional study employs Structural Equation Modelling (SEM) to explore both direct and indirect effects of parental level of education and child individual factors on the length-for-age outcomes in children aged 6-24 months assisted by the Bolsa Família Program in the State of Alagoas. A total of 1,448 children were analyzed by the SEM technique. A negative standardize direct effect (SED) of the children's younger age (SED: -0.06; p=0.017), the use of bottle feeding (SED: -0.11; p<0.001), and lack a minimum acceptable diet (SED: -0.09; p<0.001) on the length-for-age indicator was found. Being female (SDE: 0.08; p=0.001), the higher birth weight (SDE: 0.33; p<0.001), being ever breastfed (SED: 0.07; p=0.004) and a higher level of parental education (SDE: 0.09; p<0.001) showed a positive SDE effect on the child's length-for-age. The model also demonstrated a negative standardize indirect effect (SIE) of the sweet beverage consumption (SIE: -0.08; p=0.003) and a positive effect of being ever breastfed (SIE: 0.06; p=0.017) on the child's length-for-age through parental level of education as a mediator. This research underscores the crucial role of proper feeding practices and provide valuable insights for the development of targeted interventions, policies, and programs to improve the nutritional well-being and promote adequate linear growth and development among young children facing similar challenges.

Low quality of maternal and child nutritional care at the primary care in Mexico: an urgent call to action for policymakers and stakeholders.

BACKGROUND: Maternal and child malnutrition represents a public health problem in Mexico Primary care (PC) is responsible for introducing women and children under five to the health system, detecting diseases on time, and providing medical services, including pharmacological treatment if necessary. Providing these services with quality is essential to improve maternal and child health. This study evaluated the quality of nutritional care during preconception, pregnancy, postpartum, infancy, and preschool age at the PC health units across six Mexican states between 2020 and 2021. METHODS: We conducted a cross-sectional study with a mixed approach in units of the Secretary of Health to assess the quality of nutritional care during preconception, pregnancy, postpartum, childhood, and preschool age. The level of quality was calculated by the percentage of compliance with 16 indicators that integrated a Quality Index of Maternal and Child Nutritional Care (ICANMI, by its Spanish acronym). Compliance by indicator, by life stage, and overall was categorized using the following cut-off points: poor quality (≤ 70%), insufficient quality (71-89%), and good quality (≥ 90%). The perceptions of the barriers and facilitators that affect maternal and child nutrition were evaluated through semi-structured interviews with health professionals (HP) and users. All qualitative instruments were developed with a gender and intercultural perspective. RESULTS: Considering the whole sample studied, maternal and child nutritional care quality during the five life stages evaluated was bad (compliance: ≤12%), reflected in the ICANMI, which had a compliance of 8.3%. Principal barriers identified to providing high-quality nutritional care were the lack of knowledge and training of health professionals, shortages of equipment, medicine, personnel, and materials, the disappearance of the social cash transfer program Prospera, the absence of local indigenous language translators to support communication between doctor and patient, and the persistence of machismo and other practices of control over women. CONCLUSIONS: These findings underscore the need for initiatives to improve the quality of nutritional care in PC facilities across Chihuahua, State of Mexico, Veracruz, Oaxaca, Chiapas, and Yucatan. It is necessary for government and health authorities, along with various stakeholders, to collaboratively devise, implement, and assess intercultural and gender-oriented policies and programs geared towards ensuring the health infrastructure and enhancing the training of health professionals to diagnose and treat the prevalence and occurrence of diverse forms of malnutrition in both maternal and child populations.

RESUMEN: ANTECEDENTES: La mala nutrición materno-infantil (MMI) representa un problema de salud pública en México. El primer nivel tiene la respondabilidad de introducir a mujeres y niños menores de 5 años al sistema de salud, detectar oportunamente las enfermedades y brindar servicios médicos incluido el farmacológico de ser necesario. Prestar estos servicios con calidad resulta elemental para mejorar la salud de la población materno-infantil. El objetivo de este estudio fue evaluar la calidad de la atención nutricional durante las etapas de preconcepción, embarazo, posparto, infancia y edad preescolar en centros de salud de seis estados de México entre 2020 y 2021. MéTODOS: Se realizó un estudio transversal con metodología mixta en 95 centros de salud la Secretaría de Salud de México para evaluar la calidad de la atención nutricional durante la preconcepción, el embarazo, el posparto, la infancia y la etapa preescolar. El nivel de calidad se calculó mediante el porcentaje de cumplimiento de 16 indicadores que a su vez integraron un Índice de Calidad de la Atención Nutricional Materno Infantil (ICANMI). El cumplimiento por indicador, etapa de vida y global fue categorizado utilizando los siguientes puntos de corte: mala calidad (≤ 70%), calidad insuficiente (71-89%) y buena calidad (≥ 90%). La percepción sobre las barreras y facilitadores que afectan la atención nutricional materno-infantil fueron identificadas a través de entrevistas semiestructuradas y grupos focales realizadas a profesionales de salud, usuarias y usuarios. Todos los instrumentos cualitativos fueron desarrollados con un enfoque de género e interculturalidad. RESULTADOS: La calidad de la atención nutricional materno infantil durante las cinco etapas de la vida evaluadas fue mala (cumplimiento: ≤12%), mientras que el ICANMI tuvo un cumplimiento de 8.3%. Las principales barreras identificadas para brindar una atención nutricional de alta calidad fueron la falta de conocimiento y capacitación de los profesionales de la salud, la escasez de equipos, medicamentos, personal y materiales, la desaparición del programa social de transferencias monetarias Prospera, la ausencia de una lengua indígena local, entre otros. Así como la persistencia de prácticas como el machismo y otras de control sobre las mujeres. CONCLUSIONES: Estos hallazgos subrayan la necesidad inmediata de implementar iniciativas que mejoren el estándar de atención nutricional en los centros de salud en Chihuahua, Estado de México, Veracruz, Oaxaca, Chiapas y Yucatán. Es necesario que el gobierno y las autoridades sanitarias, junto con diversas partes interesadas, diseñen, implementen y evalúen en colaboración políticas y programas orientados a mejorar la calidad de la atención nutricional, con perspectiva de género e interculturalidad. Este esfuerzo tiene como objetivo mitigar la prevalencia y aparición de diversas formas de desnutrición tanto en la población materna como infantil.

Reduction in intake of discretionary foods and drinks among Danish schoolchildren: dietary results from the real-life cluster-randomised controlled trial 'Are You Too Sweet?'

OBJECTIVE: To evaluate the effectiveness of the multicomponent intervention trial 'Are You Too Sweet?' in reducing discretionary foods and drinks intake among young schoolchildren. DESIGN: The study was a 3·5-month two-arm cluster-randomised controlled trial among primary schoolchildren and their families. School health nurses provided guidance to families regarding discretionary foods and drinks for the children. Moreover, families were given a variety of knowledge- and capability-building materials to utilise at home. Dietary intake was assessed using a web-based 7-d dietary record. Linear mixed regression models were used to estimate intervention effects as changes in child intake of discretionary foods and drinks and sugar between groups. SETTING: Six schools from a Danish municipality were randomised to the intervention group (n 4) or the control group (n 2). PARTICIPANTS: A total of 153 children aged 5-7 years. RESULTS: No significant reduction in the children's intake of total discretionary foods and drinks or discretionary foods alone was observed between the intervention and control group, while a decreased intake of discretionary drinks of 40·9 % (P = 0·045) was observed compared with control. Secondary subgroup analysis showed that children of parents with shorter educational level significantly reduced their intake of added sugar by 2·9 E% (P = 0·002). CONCLUSION: The results of this study indicate that multicomponent interventions involving school health nurses may have some effects in reducing, especially, discretionary drinks.

Investigation of the Psychometric Properties of the Comprehensive Feeding Practices Questionnaire in Turkish Parents.

OBJECTIVE: The Comprehensive Feeding Practices Questionnaire (CFPQ) measures parental attitudes toward feeding practices that directly influence children's eating habits. This study aims to determine the reliability and validity of the Turkish adaptation of the CFPQ developed by Musher-Eizenman et al. DESIGN: Validity and reliability analyses were conducted for the T-CFPQ. In addition to reliability analyses and partial correlations between scale dimensions, correlations between scale dimensions according to mothers' BMI and children's BMI z-scores were also examined. SETTING: Parents with children aged 18 months to 8 years living in the community. PARTICIPANTS: The study sample consisted of 274 parents with children aged 18 months to 8 years who agreed to participate in the online survey. RESULTS: In this study, 47 items and 12-factor structure describing feeding practices were supported by CFA. Although most of the dimensions of the T-CFPQ showed significant correlations with each other, the highest correlation was found between the encourage balance/variety and the dimension of modeling and teaching nutrition (r=0.53; 0.50) (p<0.05). There was a negative correlation between the child's BMI z-score and the pressure to eat dimension (r=-0.173; p<0.01) and a positive correlation between the restriction for weight dimension (r =0.339; p<0.01). Maternal BMI was negatively associated with the involvement dimension (r=-0.121; p<0.05) and positively associated with the restriction for weight dimension (r=0.154; p<0.01). CONCLUSIONS: The findings revealed that the T-CFPQ is a valid and reliable measurement tool that can be applied to obtain the necessary information for evaluating nutritional interactions between parent and child.

Continuum of care for maternal and child health and child undernutrition in Angola.

BACKGROUND: Continuum of care (CoC) for maternal and child health provides opportunities for mothers and children to improve their nutritional status, but many children remain undernourished in Angola. This study aimed to assess the achievement level of CoC and examine the association between the CoC achievement level and child nutritional status. METHODS: We used nationally representative data from the Angola 2015-2016 Multiple Indicator and Health Survey. Completion of CoC was defined as achieving at least four antenatal care visits (4 + ANC), delivery with a skilled birth attendant (SBA), child vaccination at birth, child postnatal check within 2 months (PNC), and a series of child vaccinations at 2, 4, 6, 9 and 15 months of child age. We included under 5 years old children who were eligible for child vaccination questionnaires and their mothers. The difference in CoC achievement level among different nutritional status were presented using the Kaplan-Meier method and examined using the Log-Lank test. Additionally, the multivariable logistic regression analysis examined the associations between child nutritional status and CoC achievement levels. RESULTS: The prevalence of child stunting, underweight and wasting was 48.3%, 23.2% and 5.9% respectively. The overall CoC completion level was 1.2%. The level of achieving CoC of mother-child pairs was 62.8% for 4 + ANC, 42.2% for SBA, 23.0% for child vaccination at birth, and 6.7% for PNC, and it continued to decline over 15 months. The Log-Lank test showed that there were significant differences in the CoC achievement level between children with no stunting and those with stunting (p < 0.001), those with no underweight and those with underweight (p < 0.001), those with no wasting and those with wasting (p = 0.003), and those with malnutrition and those with a normal nutritional status (p < 0.001). Achieving 4 + ANC (CoC1), 4 + ANC and SBA (CoC 2), and 4 + ANC, SBA, and child vaccination at birth (CoC 3) were associated with reduction in child stunting and underweight. CONCLUSIONS: The completion of CoC is low in Angola and many children miss their opportunity of nutritional intervention. According to our result, improving care utilization and its continuity could improve child nutritional status.

The role of dairy consumption in the relationship between wealth and early life physical growth in India: evidence from multiple national surveys.

INTRODUCTION: Prevalence of undernutrition continues to be high in India and low household wealth is consistently associated with undernutrition. This association could be modified through improved dietary intake, including dairy consumption in young children. The beneficial effect of dairy on child growth has not been explored at a national level in India. The present analyses aimed to evaluate the direct and indirect (modifying association of household level per adult female equivalent milk and milk product consumption) associations between household wealth index on height for age (HAZ) and weight for age (WAZ) in 6-59 months old Indian children using data from of nationally representative surveys. METHODS: Two triangulated datasets of two rounds of National Family Health Survey, (NFHS-3 and 4) and food expenditure (National Sample Survey, NSS61 and 68) surveys, were produced by statistical matching of households using Non-Iterative Bayesian Approach to Statistical Matching technique. A Directed Acyclic Graph was constructed to map the pathways in the relationship of household wealth with HAZ and WAZ based on literature. The direct association of wealth index and its indirect association through per adult female equivalent dairy consumption on HAZ and WAZ were estimated using separate path models for each round of the surveys. RESULTS: Wealth index was directly associated with HAZ and WAZ in both the rounds, but the association decreased from NFHS-3 (ßHAZ: 0.145; 95% CI: 0.129, 0.16) to NFHS-4 (ßHAZ: 0.102; 95%CI: 0.093, 0.11). Adult female equivalent milk intake (increase of 10gm/day) was associated with higher HAZ (ß_NFHS-3=0.001;95% CI: 0, 0.002; ß_NFHS-4=0.002;95% CI: 0.002, 0.003) but had no association with WAZ. The indirect association of wealth with HAZ through dairy consumption was 2-fold higher in NFHS-4 compared to NFHS-3. CONCLUSIONS: The analysis of triangulated survey data shows that household level per- adult female equivalent dairy consumption positively modified the association between wealth index and HAZ, suggesting that regular inclusion of milk and milk products in the diets of children from households across all wealth quintiles could improve linear growth in this population.

Timely initiation of complementary feeding and associated factors among mothers having children aged 6 to 24 months in North-West Ethiopia: a comparative cross-sectional study.

BACKGROUND: The timely introduction of complementary foods during infancy is necessary for nutritional reasons, and to enable the transition from milk feeding to family foods. In the past years, despite efforts that have been put to increase the utilization of timely initiation of complementary feeding practice in Ethiopia, improvements are not satisfactory. OBJECTIVE: To compare the prevalence of timely initiation of complementary feeding and its associated factors among mothers who have Children 6-24 months in Debre Tabor town and rural Farta district, North-west Ethiopia, 2021. METHODS: A community-based comparative cross-sectional study was employed from December 1/2020 to 30/ 2020 among 1100 mothers. Data were collected using a structured questioner and analyzed using Statistical Product and Service Solutions. Logistic regression analysis with a 95% confidence interval carried out to determine the association between explanatory and the outcome variables. A P-value of < 0.05 was considered statistically significant. RESULTS: The prevalence of timely initiation of complementary feeding among urban and rural mothers was 69.8% with (95% CI: 66%, 74%) and 51.9% with (95% CI: 48- 56%) respectively. Urban residence [AOR = 1.39, 95% CI: (1.02-1.94)], had antenatal care visits [AOR = 0.24 (95%CI: (0.13, 0.44)], had post natal care checkups [AOR = 0.44, 95%CI: (0. 27- 0.72)] and being a governmental employee [AOR = 2.82; 95% CI: (1.91-6.1)] were factors associated with timely initiation of complementary feeding among urban mothers. Whereas in rural settings: institutional delivery [(AOR = 2.21, CI: 1.35-3.65)], post natal care checkups [(AOR = 0.53, CI: (0.36-0.77)] being daily laborer [AOR = 3.47; 95% CI: (1.78-6.75)] were associated with timely initiation of complementary feeding. CONCLUSION: The prevalence of timely introduction of complementary feeding in children aged 6-24 months is still low in the study areas. There was also disparity between urban and rural mothers in which urban mothers practiced better.

'Counselling is not just providing information': perceptions of caregivers and stakeholders on the design of nutrition and health counselling interventions for families with young children in rural Kenya.

BACKGROUND: Globally, a fifth of the children continue to face chronic undernutrition with a majority of them situated in the Low- and Middle-Income Countries (LMIC). The rising numbers are attributed to aggravating factors like limited nutrition knowledge, poor feeding practices, seasonal food insecurity, and diseases. Interventions targeting behaviour change may reduce the devastating nutrition situation of children in the LMICs. OBJECTIVE: For the co-design of a Behaviour Change Communication (BCC) intervention for young children in rural Kenya, we aimed to identify the experiences, barriers, facilitators, and preferences of caregivers and stakeholders regarding nutrition and health counselling. DESIGN: We employed a qualitative study design and used a semi-structured interview guide. The in-depth interviews were recorded, transcribed, and analysed using content analysis, facilitated by the software NVivo. SETTING: Health and Demographic Surveillance System (HDSS) area in Siaya County, rural Kenya. PARTICIPANTS: We interviewed 30 caregivers of children between 6 and 23 months of age and 29 local stakeholders with experience in implementing nutrition projects in Kenya. RESULTS: Nutrition and health counselling (NHC) was usually conducted in hospital settings with groups of mothers. Barriers to counselling were long queues and delays, long distances and high travel costs, the inapplicability of the counselling content, lack of spousal support, and a high domestic workload. Facilitators included the trust of caregivers in Community Health Volunteers (CHVs) and counselling services offered free of charge. Preferences comprised (1) delivering of counselling by CHVs, (2) offering individual and group counselling, (3) targeting male and female caregivers. CONCLUSION: There is a disconnect between the caregivers' preferences and the services currently offered. Among these families, a successful BCC strategy that employs nutrition and health counselling should apply a community-based communication channel through trusted CHVs, addressing male and female caregivers, and comprising group and individual sessions.

A systematic review of articles influencing United States retail cheese packaging, labeling, and market trends related to cheese in the marketplace and cheese during consumption.

Innovation around cheese is constant in attempts to meet ever-increasing consumer demands. Retail packaging provides a canvas to communicate to consumers added value from innovations or inherent properties of cheese. Packaging itself may also be the subject of cheese-related innovation. This systematic review of literature organizes research over the past 10 years related to cheese packaging innovation that consumers experience in the marketplace and during consumption of cheese products. The review discusses shipping, displaying cheese at grocery stores, the value of branding, purchasing preferences by demographics, health and nutrition claims, opportunities to highlight protein in cheese, marketing to children, issues of obesity and cheese, diet cheeses, allergens and non-dairy or vegan cheese, opening cheese packaging, cutting of cheese, cooking with cheese, eating cheese, the growing trend of snacking and convenience, and flavor preferences. This review provides helpful insights to cheese producers applying findings from research of various styles of cheeses, cheese marketers communicating effectively to consumers, cheese developers designing new products relevant to recent consumer demands, smaller or specialized companies seeking to differentiate their cheese product through available technology and strategy, and cheese lovers or those with hobbies surrounding food wanting to know recent advancements in cheese packaging. This review is a tool for discovering relevant articles relating to cheese packaging in a marketplace and consumption setting to guide cheese and cheese packaging and labeling innovation in the United States.

Effect of cashew nut flour on hematological parameters of children living with HIV.

Aim: To assess the effect of cashew nut flour on the hematological parameters of children living with HIV-AIDS. Method: A 32-week randomized, blind clinical trial conducted at a specialized outpatient clinic. Children aged 2-12 years were allocated to intervention groups (IGs) (n = 11) receiving 12 g/day of cashew nut flour and control groups (CGs) (n = 9) receiving 12 g/day of carboxymethyl cellulose. Parameters of erythrocytes, leukocytes, platelets, and lipid profiles were evaluated. Results: In the IG, the elevation and reduction of leukocyte and lipid profile biomarkers, respectively, were not statistically significant (p > 0.05). A clinically and statistically significant increase in mean corpuscular hemoglobin concentration was observed in the CG (p = 0.018), with a large effect size (Cohen's d = 0.9). There were no statistically significant changes in platelet counts among participants (p = 0.18). The effect size for white blood cell count, low-density lipoprotein cholesterol, very low-density lipoprotein, and triglycerides was moderate in the IG compared to the CG. Conclusion: Cashew nut flour supplementation may increase levels of leukocytes and lipid profile parameters in children living with HIV. Brazilian Clinical Trials Registry (REBEC): U1111.1276.6591.

Text messages to improve young child diets: Results from a cluster-randomized controlled trial in Kanchanpur, Nepal.

The objective of this study was to test whether adding a text message campaign about the importance of eating eggs and other nutrition-related behaviours to an on-going package of large-scale, diverse social and behaviour change interventions would improve four types of nutrition-related knowledge and behaviour outcomes: child diets (egg consumption as the primary outcome), maternal diets, maternal nutrition knowledge, and maternal participation in additional interventions. The cluster-randomized controlled trial involved a repeat cross-sectional design, recruiting families with children 12-23 months of age at baseline and endline in one plains district of Nepal. Throughout the 1000-day period, 51 text messages were sent to each household at specific time points to reinforce ideal diets and other nutrition-related practices and promote engagement with community health workers and other intervention platforms. The primary outcome was egg consumption and dietary diversity among young children. We found no population-level effect. Some evidence supports that for those who received and opened the SMS intervention, it improved child egg consumption (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.03-1.93), child minimum dietary diversity (OR: 1.36, 95% CI: 1.07-1.73), child dietary diversity scores (ß: 0.15, 95% CI: 0.01-0.24), as well as maternal IYCF knowledge (ß: 0.21, 95% CI: 0.08-0.35), participation in health mothers' group meetings (OR: 3.03, 95% CI: 1.91-4.84) and Bhanchhin Aama listenership (OR: 1.36, 95% CI: 1.07-1.73). This study highlights the importance of more research to understand the effectiveness of emerging digital interventions for behaviour change among specific populations, to facilitate nuanced targeting to those who can best benefit from these investments. Registered at clinicaltrials.gov with identifier NCT03926689.

Identifying and understanding barriers to optimal complementary feeding in Kenya.

Optimal complementary feeding between the ages of 6 and 23 months provides children with the required range of nutritious and safe foods while continuing to be breastfed to meet their needs for essential nutrients and develop their full physical and cognitive potential. The rates of exclusive breastfeeding in the first 6 months of life have increased from 32% in 2008 to 60% in 2022 in Kenya. However, the proportion of children between 6 and 23 months receiving a minimum acceptable diet remains low and has declined from 39% in 2008 to 31% in 2023. The Kenyan Ministry of Health, GAIN and UNICEF collaborated to understand the drivers of complementary feeding practices, particularly proximal determinants, which can be directly addressed and acted upon. A secondary analysis of household surveys and food composition data was conducted to outline children's dietary patterns within the different regions of Kenya and the extent to which the affordability of animal-source foods could be improved. Ethnographic data were analyzed to identify socio-cultural barriers to optimal complementary feeding. Furthermore, we outlined the critical steps for developing user-friendly and low-cost complementary feeding recipes. The results of all the analyses are presented in five of the six papers of this Special Issue with this additional paper introducing the Kenyan context and some of the critical findings. The Special Issue has highlighted multidimensional barriers surrounding the use and availability of animal-source foods. Furthermore, it emphasizes the need for a multi-sectoral approach in enacting policies and programmes that address these barriers.

The prevalence of anemia during pregnancy and its correlates vary by trimester and hemoglobin assessment method in Eastern Maharashtra, India.

Approximately half of pregnant women in India are anemic, representing over 7.5 million women. Few studies have assessed the relationship between multiple micronutrient deficiencies and anemia during pregnancy or the trajectory of hemoglobin (Hb) during pregnancy in low-resource settings. We enrolled 200 pregnant women from the Maternal and Newborn Health (MNH) registry, a population-based pregnancy and birth registry in Eastern Maharashtra, India to address these gaps. The women provided capillary (finger-prick) and venous blood specimens at enrollment (<15 weeks), and a second capillary specimen in the 3rd trimester (>27 weeks). Capillary specimens were analyzed at the time of collection with a HemoCue Hb 201+; venous specimens were shipped on dry ice to a laboratory for cyanmethemoglobin assessment. In the 1st trimester, mean Hb concentration and anemia (Hb<11.0 g/dL) prevalence using capillary specimens were 10.9 ± 1.5 g/dL and 51.1%; mean Hb concentration using venous blood specimens was estimated to be 11.3 ± 1.3 g/dL and anemia prevalence was 37.5%. The prevalence of iron, vitamin B12 and folate deficiencies were 40%, 30% and 0%, respectively. Among women with anemia in the 1st trimester (venous blood), 56% had concurrent iron deficiency (inflammation-adjusted serum ferritin <15 µg/L) indicating that their anemia may be amenable to iron supplementation. In total, 21% of women had ID and anemia, 19% ID in the absence of anemia, 16.5% anemia in the absence of ID and 43.5% had neither. By the 3rd trimester, mean Hb from capillary specimens had declined to 10.1 ± 1.35 g/dL and anemia prevalence increased to 70.7%, despite 99.4% mothers reporting receipt of iron-folic acid (IFA) supplements during her current pregnancy, and 83.9% reporting IFA consumption the previous day. Significant predictors of anemia in the 1st trimester (both venous and capillary) included the number of weeks gestation at the time of Hb assessment and inflammation-adjusted serum ferritin. For 3rd trimester anemia, significant predictors included 1st trimester height, BMI and IFA consumption during the 3rd trimester (but not 1st trimester micronutrient biomarkers), indicating that IFA supplementation over the course of pregnancy may have influenced micronutrient status and anemia risk. Our findings highlight the severity of the burden of anemia and micronutrient deficiencies in Eastern Maharashtra, but also highlight that in many cases, ID and anemia affect different individuals. Preventing and managing anemia in pregnancy in India will require strengthening both clinical and community-based strategies targeting iron deficiency, as well as other causes of anemia.

Improving complementary feeding practices, programs and policies for optimal early childhood nutrition in Kenya: What would work?

Complementary feeding practices are greatly influenced by local contexts. Therefore, national home-grown evidence, policies and guidelines are critical to improving infant and young children's diets. This Special Issue has provided a comprehensive, evidence-based analysis of the situation, gaps and context-specific opportunities for improving young children's diets in Kenya. The primary research findings of the Special Issue supported the identification of a set of recommendations articulated across the four systems (food, health, water, sanitation and hygiene [WASH] and social protection) to improve food availability and accessibility in Kenya at the national and subnational levels. It is anticipated that the decentralised government functions seen in Kenya provide a strong opportunity to develop and mainstream context-specific recommendations into action. This Special Issue recommends adopting a multi-sectoral systems approach, including a shared vision, joint planning, implementation and monitoring, towards improving young children's diets with a focus on service delivery as well as scaled-up community social behaviour change interventions. In particular, the approach should entail advocacy for policy revisions for service delivery that support complementary feeding and development of costed implementation strategies in support of the same, across four critical systems-food, health, WASH and social protection, along with, the strengthening of national coordination, monitoring and accountability structures as per the Kenya Nutrition Action Plan. Finally, the development of a legal framework for enhanced accountability from all relevant sectors towards sustainable, nutritious, safe and affordable children's diets. These recommendations provide a clear direction in addressing the complementary feeding challenges, which the primary research of this Special Issue has presented.

A repeated cross-sectional analysis of the Icelandic baby food market surveyed in 2016, 2019 and 2021.

World Health Organisation (WHO) has stated that countries need to know their local commercial baby food (CBF) market. Data from other countries suggest rapid changes in CBF options, highlighting the need for repeated analysis. In that context, this repeated cross-sectional study analysed the options and nutrient quality of different CBF types available in Iceland in years 2016, 2019 and 2021. Data was gathered on formulas, porridge flours, foods in jars and pouches, finger-foods, other CBF. They were classified into 26 subgroups based on ingredients and taste (sweet/savoury). Minimum consumer age as suggested by the manufacturers and nutritional content were registered. In each data-collection, 250-275 products were available. Over a third of products (37%-44%) were in pouches. Availability of products intended for 4-11-month-old infants decreased, driven largely by a 65% decrease in availability of food in jars (sweet/savoury) between 2016 and 2021. Availability of products intended from 12+ months or without age-labels increased, driven largely by quadrupling of finger-foods (predominantly sweet) between 2016 and 2021. The overall percentage of products classified as sweet increased from 65% (2016) to 73% (2019) and 77% (2021). Some finger-foods had high sugar content (up to 72 g/100 g), partly from fruit concentrate or sugar/syrup. Like other countries, the Icelandic CBF market has moved towards less availability of food intended in the first year and more availability of sweet finger-foods for an expanded consumer age. As sugar is added to some CBF, stronger regulations on promotion of foods for young consumers and updated recommendations for parents/caregivers may be needed.

A qualitative study of public health nurses' perspectives and experiences on nutritional guidance for parents of infants and toddlers.

In Norway, public health nurses (PHNs) are responsible for giving parents nutritional knowledge, but limited research describes how they perceive this task. This study explores PHNs' perceptions and experiences on nutritional guidance for parents of infants and toddlers. Semistructured interviews with six PHNs were conducted and transcribed verbatim. Data were subjected to thematic analysis. Five main themes were identified: (1) Dietary guidance for parents is central to the work; (2) PHNs perceive they have parents' trust, and parents are in general open to nutrition counselling; (3) food and meals must be seen in light of the family context; (4) The dialogue must be adapted to the individual family; and (5) PHNs have expertise on nutrition; however, updating knowledge is difficult. Nutritional guidance was perceived by PHNs as a core activity. They felt that they had parents' trust, and that parents were particularly open to nutritional guidance during the first 2 years. Counselling was generally well received, but conversations on overweight were perceived as difficult. PHNs strove to tailor their guidance to individual needs. However, providing guidance on a wide range of issues in different families and cultures could be challenging. They acknowledged a need for updating knowledge but the offer of courses was sparse. Our findings suggest a discrepancy between how nutrition is prioritized in the education of PHNs and what they encounter in clinical practice. In the future, this should be given more attention given the PHNs' unique position to promote healthy eating and long-term health.

Maternal mental health is associated with children's frequency of family meals at 12 and 24 months of age.

Diet during the child's first years is important for growth and development. In toddlerhood, higher diet quality is reported among children eating meals together with family. Although previous literature has documented several associations between maternal mental health and early child feeding practices, less is known about the relationship between maternal mental health and child frequency of shared family meals. This study explores associations between maternal symptoms of anxiety and depression, measured by The Hopkins Symptoms Checklist (SCL-8), and toddler participation in family meals. We used cross-sectional data from the Norwegian study Early Food for Future Health, in which participants responded to questionnaires at child age 12 (n = 455) and 24 months (n = 295). Logistic regression was used to explore associations between maternal mental health and child having regular (≥5 per week) or irregular (<5 per week) family meals (breakfast and dinner), adjusting for relevant child and maternal confounding variables. Children of mothers with higher scores of anxiety and depression had higher odds of Irregular family meals at both timepoints; (OR: 2.067, p = 0.015) and (OR: 2.444, p = 0.023). This is one of few studies exploring associations between maternal mental health and child frequency of shared family meals in early childhood, a period where the foundation for life-long health is shaped. Given the high prevalence of mental ailments and disorders, these findings are important and may inform future public health interventions. Further exploration of this relation is needed, including longitudinal research to test predictive associations and qualitative studies to increase insight and understanding.

Development of the generic Community Infant and Young Child Feeding Counselling Package.

Infant and young child feeding (IYCF) promotion is a key component in the set of high impact interventions to improve nutrition. The literature provides evidence of the positive impact of IYCF promotion through various platforms, including communities. In 2009, UNICEF and WHO agreed that a global, "generic" IYCF package of resources and tools to plan, implement, and monitor community-based IYCF programmes and to build skills of community-based workers was needed. In 2010, the UNICEF Community Infant and Young Child Feeding Counselling Package was finalized and field tested under a strategic collaboration between UNICEF New York and Nutrition Policy and Practice and the Center for Human Services/University Research Company. The Package includes 11 tools to guide adaptation of the materials, the design, planning, and implementation of IYCF programmes and the training, monitoring, supervision, and mentoring of community workers, using an interactive and experiential adult learning approach. The Package was rolled out from 2011 onwards and by 2017 was implemented in 87 countries. In 2013, UNICEF and the United States Agency for International Development-funded Strengthening Partnerships, Results, and Innovations in Nutrition Globally project started planning the evaluation, and a study site was selected in Nigeria to assess the efficacy and effectiveness of the Package on IYCF practices, knowledge, and worker skills. This article describes the need for and development of the Package, its content and approach to skills building, as well as its current implementation. Finally, it makes the case for the evaluation of the Package, which is covered in the other papers in the Supplement in relation to the Nigeria evaluation.

Formulation and acceptability of local nutrient-dense foods for young children: A formative study for the Child Health, Agriculture and Integrated Nutrition (CHAIN) Trial in rural Zimbabwe.

Stunting affects almost one-quarter of children globally, leading to reduced human capacity and increased long-term risk of chronic disease. Despite intensive infant and young child feeding (IYCF) interventions, many children do not meet their requirements for essential nutrients. This study aimed to assess the feasibility of implementing an IYCF intervention utilizing nutrient-dense powders from egg, biofortified sugar beans and Moringa oleifera leaf in rural Zimbabwe. A mixed-methods formative study was conducted comprising the following: (i) a recipe formulation trial, (ii) trials of improved practices to assess acceptability of the intervention, and (iii) a participatory message formulation process to develop counselling modules for the IYCF-plus intervention. Twenty-seven mother-baby pairs were recruited between November 2019 and April 2020. Key domains affecting IYCF practices that emerged were time, emotional and physical space, cultural and religious beliefs, indigenous knowledge systems and gender dynamics. Household observations and sensory evaluation indicated high acceptability of the new ingredients. Recipe formulation and participatory message formulation by participants instilled community ownership and served to demystify existing misconceptions about the new food products. Families noted the potential for intervention sustainability because the foods could be grown locally. Supplementing complementary foods with nutrient-dense local food ingredients as powders has the potential to sustainably address nutrient-gaps in the diets of young children living in rural lower- and middle-income countries. Comprehensive IYCF counselling utilizing a gender-lens approach, family support and indigenous knowledge systems or resources are key elements to support positive behaviour change in complementary feeding interventions.

Mothers' sociodemographic factors and use of health professionals for child feeding advice.

This study examined sociodemographic factors associated with mothers seeking child feeding advice from health professionals (HPs). Cross-sectional analysis of survey data from linked randomized controlled trials was conducted. Surveys asked which sources of feeding information mothers used when their child was 6 months and 5 years old. Logistic regression was used to examine associations between sociodemographic characteristics and use of information from HPs. Here, 947 and 405 mothers completed 6-month and 5-year surveys, respectively. At 6 months, multiparous mothers were less likely to seek advice from child and family health nurses (CFHNs) (adjusted odds ratio [AOR]: 0.558, 95% confidence interval [95% CI]: 0.416-0.749) and other HPs (AOR: 0.706, 95% CI: 0.542-0.919), unmarried mothers were less likely to seek advice from other HPs (AOR: 0.582, 95% CI: 0.342-0.990). At 5 years, mothers with household income ≥$80,000 p.a. were less likely to seek advice from CFHNs (AOR: 0.514, 95% CI: 0.302-0.875) and working mothers less likely to seek advice from general practitioners (GPs) (AOR: 0.581, 95% CI: 0.374-0.905). Mothers born in Australia were less likely to seek information from CFHNs (AOR: 0.462, 95% CI: 0.257-0.833) and GPs (AOR: 0.431, 95% CI: 0.274-0.677). There was a greater likelihood that multiparous mothers (AOR: 2.114, 95% CI: 1.272-3.516) and mothers of children whose fathers had not attended university (AOR: 2.081, 95% CI: 1.256-3.449) had never sought advice from CFHNs, and that mothers who had not attended university (AOR: 1.769, 95% CI: 1.025-3.051), multiparous (AOR: 1.831, 95% CI: 1.105-3.035) and employed (AOR: 2.058, 95% CI: 1.135-3.733) mothers had never sought advice from other HPs. Understanding sociodemographic factors associated with seeking child feeding advice from HPs may inform priorities for engaging families in health promotion.