A Qualitative Exploration of the Determinants of Exclusive Breastfeeding (EBF) Practices in Wajir County, Kenya.

BACKGROUND: The World Health Organization recommends exclusive breastfeeding for the first six months of life. A qualitative study was conducted to assess the factors that influence the practice of exclusive breastfeeding amongst mothers attending Wajir County Hospital, Kenya. METHOD: This study was part of a cross-sectional study to compare the exclusive breastfeeding rates amongst primiparous and multiparous mothers with infants under 6 months old attending Wajir County Hospital. Focus group discussions and key informant interviews were conducted to collect information on exclusive breastfeeding and related factors. Four focus group discussions were conducted with mothers who exclusively breastfed and the same number with mothers who did not exclusively breastfeed their babies. Key informant interviews were conducted with nine healthcare providers. The data were transcribed, and a content analysis identified common themes and inferences. RESULTS: The exclusive breastfeeding rate among the mothers in the larger study was 45.5%. There was no disparity between the practice of exclusive breastfeeding between primiparous and multiparous mothers. Despite the high knowledge and positive attitudes towards exclusive breastfeeding of most mothers, the practice of exclusive breastfeeding was unsatisfactory. The major hindrances identified were cultural barriers propagated by mothers-in-law and traditional birth attendants; the belief that babies cannot live without water; and a few unsupportive health workers. The uptake of exclusive breastfeeding was enhanced by Islamic teaching on breastfeeding, education from a few supportive healthcare providers; support from husbands; and positive deviance among some lactating mothers who practiced exclusive breastfeeding. CONCLUSIONS: Deeply rooted cultural factors were the major hindrance to the practice of exclusive breastfeeding. Most of the mothers did not practice exclusive breastfeeding, despite the majority being knowledgeable and having positive attitudes towards the practice. The influence of mother-in-law's and traditional birth assistants were major barriers. Strengthening the Community Health Strategy through training traditional birth attendants on Infant Young Child Nutrition practices, designing mechanisms linking traditional birth assistants to existing health facilities for support, and capacity building and monitoring is critical in promoting exclusive breastfeeding. Behavior change and communication through multiple channels within the community should be utilized to maximize promotion of exclusive breastfeeding among all stakeholders.

Effect of locally produced complementary foods on fat-free mass, linear growth, and iron status among Kenyan infants: A randomized controlled trial.

The impact of quality complementary food products on infant growth and body composition has not been adequately investigated. This study evaluated the effect on fat-free mass (FFM) accrual, linear growth, and iron status of locally produced complementary food products comparing to a standard product. In a randomized, double-blind trial, 499 infants at 6 months received nine monthly rations of (a) WinFood Classic (WFC) comprising germinated amaranth (71%), maize (10.4%), small fish (3%), and edible termites (10%); (b) WinFood Lite (WFL) comprising germinated amaranth (82.5%), maize (10.2%), and multimicronutrient premix; or (c) fortified corn-soy blend plus (CSB+). Primary outcomes were changes in FFM, length, and plasma ferritin and transferrin receptors (TfR). FFM was determined using deuterium dilution. Analysis was by intention to treat, based on available cases. Compared with CSB+, there were no differences in change from 6 to 15 months in FFM for WFC 0.0 kg (95% CI [-0.30, 0.29]) and WFL 0.03 kg (95% CI [-0.25, 0.32]) and length change for WFC -0.3 cm (95% CI [-0.9, 0.4]) and WFL -0.3 cm (95% CI [-0.9, 0.3]). TfR increased in WFC group 3.3 mg L-1 (95% CI [1.7, 4.9]) and WFL group 1.7 mg L-1 (95% CI [0.1, 3.4]) compared with CSB+. Compared with the increase in Hb in CSB+ group, there was a reduction in Hb in WFC of -0.9 g dl-1 (95% CI [-1.3, -0.5]) and a lower increase in WFL -0.4 g dl-1 (95% CI [-0.8, 0.0]). In conclusion, the tested WinFoods had the same effect on FFM and length as CSB+, whereas Hb and iron status decreased, suggesting inhibited iron bioavailability from the amaranth-based WinFoods.

WinFood data from Kenya and Cambodia: constraints on field procedures.

BACKGROUND: Researchers face myriad challenges in the design and implementation of randomized, controlled trials. Apart from summaries on limitations, these challenges are rarely documented in detail to inform future research projects. OBJECTIVE: To describe methodological challenges encountered during randomized, controlled trials (WinFood Study) designed to assess the efficacy of locally produced complementary foods based on traditional animal-source foods (edible termites and spiders) to support growth and nutritional status in Kenyan and Cambodian infants. METHODS: In a randomized, controlled design, infants received WinFood or corn-soy blend (CSB) for 9 months from 6 to 15 months of age. Lean mass accrual and blood nutrition indicators (lipid profile, iron and zinc status) were measured cross-sectionally at 9 and 15 months of age, respectively. Lean mass was determined by measuring deuterium oxide enrichment in saliva samples following a standard dose of deuterium solution (0.5 g/kg body weight) to infants. Blood nutrition indicators were determined following the drawing of 3 mL of blood by venipuncture. RESULTS: Challenges included rapid depletion of food rations, high rate of loss to follow-up, delayed ethical approval, lack of local food-processing capacity, low capacity among staff to draw blood, and lack of laboratory capacity to perform both deuterium oxide and micronutrient status measurements. Spillage of deuterium oxide solution during dosing was a major challenge in the Kenya context. A high rate of morbidity among infants made some assessments very difficult, especially drawing of blood and saliva samples. CONCLUSIONS: The challenges were largely contextual. Improvement of local laboratory capacity, training of staff and sensitization of the communities and the Ethics Review Committee are highly recommended.

Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial.

Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto. This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome. The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group. In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.

Development and acceptability of a novel milk-free soybean-maize-sorghum ready-to-use therapeutic food (SMS-RUTF) based on industrial extrusion cooking process.

Peanut milk-based ready-to-use therapeutic food (P-RUTF) primarily used to treat severe acute malnutrition at community setting is expensive. We developed an alternative milk-free soybean-maize-sorghum-based RUTF (SMS-RUTF) using locally grown ingredients that have the potential to support local economy and reduce the cost of RUTF. We describe the production process and results of acceptability of the new product. Acceptability and tolerance of SMS-RUTF was compared with P-RUTF among 45 children aged 4-11 years old based on a cross-over design. Each child consumed 250 g RUTF for 10 days followed by a five-day washout period and a subsequent 10-day period on the second RUTF. The SMS-RUTF was as acceptable as the P-RUTF among normal children aged 4-11 years of age with no associated adverse effects. SMS-RUTF was stable for at least 12 months without detectable microbiological or chemical deterioration. The major challenge encountered in SMS-RUTF development was the difficulty to accurately determine key nutrient composition due to its high oil content. Use of diversified locally available ingredients to produce RUTF is feasible. The SMS-RUTF meets expected standards and is acceptable to children aged 4-11 months old. Effectiveness and cost-effectiveness of SMS-RUTF is required.

Randomized controlled trial of the effectiveness of a soybean-maize-sorghum-based ready-to-use complementary food paste on infant growth in South Kivu, Democratic Republic of Congo.

BACKGROUND: Evidence of the effectiveness of lipid-based ready-to-use complementary foods (RUCF) at improving linear growth among infants aged 6-12 mo is scarce, and further work is warranted. OBJECTIVE: The objective was to assess the effectiveness of a fortified soybean-maize-sorghum RUCF paste compared with a fortified corn soy blend (UNIMIX) porridge on the prevalence of underweight and stunting among infants in South Kivu Province, Democratic Republic of Congo. DESIGN: Infants were randomly assigned at 6 mo of age to receive either RUCF (n = 691) or UNIMIX (n = 692) for 6 mo. In addition to admission and monthly anthropometric measurements, hemoglobin, triglyceride, and cholesterol were measured at enrollment and at the end of the study. RESULTS: No significant differences in the prevalence of stunting (RUCF: 48.6%; UNIMIX: 46.4%; P = 0.31), the prevalence of underweight (RUCF: 20.4%; UNIMIX: 18.2%; P = 0.42), or weight gain (RUCF: 1.2 ± 0.7 kg; UNIMIX: 1.3 ± 0.7 kg; P = 0.08) were found. A small but statistically significant difference in length gain (RUCF: 5.2 ± 2.0; UNIMIX: 5.4 ± 2.0; P = 0.03) was found. No significant differences in the concentrations of hemoglobin, serum triglyceride, and serum cholesterol were found between the 2 groups. CONCLUSION: No significant differences were found between the RUCF and UNIMIX in the reduction of the prevalence of stunting and underweight at 12 mo of age among rural Congolese infants. This trial was registered at controlled-trials.com as ISRCTN20267635.

Fortified complementary foods with or without alpha-amylase treatment increase hemoglobin but do not reduce breast milk intake of 9-mo-old Zambian infants.

BACKGROUND: Malnutrition in late infancy in developing countries may result from poor-quality complementary foods that displace breast milk. OBJECTIVE: The objective of the study was to assess the effects of fortified complementary blends of different energy densities on growth, hemoglobin concentrations, and breast milk intake of 9-mo-old Zambian infants. DESIGN: Infants were randomly assigned at 6 mo of age to receive for 3 mo a fortified blend of maize, beans, bambaranuts, and groundnuts [Chilenje Baby Mix (CBM); energy density: 68 kcal/100 g; n = 37] or a similar blend with alpha-amylase (CBMA; energy density: 106 kcal/100 g; n = 44). Cross-sectional data were obtained at 9 mo for a control group of infants (n = 69) not given the diets. Breast milk intake was measured by using the dose-to-the-mother deuterium dilution technique. RESULTS: No differences in weight or length z scores, all of which were within normal ranges, were seen between groups at 9 mo. Percentage fat mass was significantly (P = 0.01) greater in the infants in both the CBM (23.2 +/- 2.7%) and CBMA (23.4 +/- 2.5%) groups than in the control group (21.6 +/- 2.6%). Hemoglobin concentrations were significantly (P = 0.03) greater in both intervention groups (CBM group: 104 +/- 12 g/L: CBMA group: 103 +/- 12 g/L) than in the control group (98 +/- 14 g/L). Breast milk intake was not significantly (P = 0.87) different between groups (CBM group: 614 +/- 271 g/d; CBMA group: 635 +/- 193 g/d; control group: 653 +/- 221 g/d). CONCLUSIONS: The study foods improved hemoglobin concentrations without reducing breast milk intake and may be used to improve the nutritional status of infants in developing countries.