Gender differences in nutritional status and determinants among infants (6-11 m): a cross-sectional study in two regions in Ethiopia.

BACKGROUND: A limited number of studies suggest that boys may have a higher risk of stunting than girls in low-income countries. Little is known about the causes of these gender differences. The objective of the study was to assess gender differences in nutritional status and its determinants among infants in Ethiopia. METHODS: We analyzed data for 2036 children (6-11 months old) collected as the baseline for a multiple micronutrient powders effectiveness study in two regions of Ethiopia in March-April 2015. Child, mother, and household characteristics were investigated as determinants of stunting and wasting. Multiple logistic regression models were used separately for boys and girls to check for gender differences while adjusting for confounders. The study is registered at http://www.clinicaltrials.gov/ with the clinical trials identifier of NCT02479815. RESULTS: Stunting and wasting prevalence is significantly higher among boys compared to girls, 18.7 vs 10.7% and 7.9 vs 5.4%, respectively. Untimely initiation of breastfeeding, not-exclusive breastfeeding at the age of 6 months, region of residence, and low maternal education are significant predictors of stunting in boys. Untimely introduction to complementary food and low consumption of legumes/nuts are significant predictors of stunting in both boys and girls, and low egg consumption only in girls. Region of residence and age of the mother are significant determinants of wasting in both sexes. Analysis of interaction terms for stunting, however, shows no differences in predictors between boys and girls; only for untimely initiation of breastfeeding do the results for boys (OR 1.46; 95%CI 1.02,2.08) and girls (OR 0.88; 95%CI 0.55,1.41) tend to be different (p = 0.12). CONCLUSION: In Ethiopia, boys are more malnourished than girls. Exclusive breastfeeding and adequate dietary diversity of complementary feeding are important determinants of stunting in boys and girls. There are no clear gender interactions for the main determinants of stunting and wasting. These findings suggest that appropriate gender-sensitive guidance on optimum infant and young child feeding practices is needed.

Determinants of adherence to micronutrient powder use among young children in Ethiopia.

In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale-up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6-11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother's age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66-0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54-0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52-0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled-up, by taking into account factors that positively and negatively determine adherence.

Provision of low-iron micronutrient powders on alternate days is associated with lower prevalence of anaemia, stunting, and improved motor milestone acquisition in the first year of life: A retrospective cohort study in rural Ethiopia.

Inappropriate complementary feeding contributes to growth faltering, anaemia, and cognitive impairments. Limited programmatic evidence exists on the effectiveness of low-iron micronutrient powders (MNPs) on anaemia and motor development when provided every other day in the first year of life. This study used an existing demonstration project to evaluate associations between exposure of low-iron MNPs, anaemia, and motor development of infants in Southern Ethiopia. Using a retrospective cohort design, 200 infants aged 9 to 12 months (98 MNP exposed; 102 unexposed) were recruited, and data on socio-economic characteristics, anthropometric measures, dietary diversity scores (DDS), haemoglobin concentrations, and motor development acquisition were collected, and MNP exposed and unexposed groups were compared. Logistic regressions were run to identify predictors of acquisition of motor development milestones. Sociodemographic characteristics and dietary diversity scores were similar between MNP exposed and unexposed groups. Provision of low-iron (6 mg) MNP every other day, for 3 months, was associated with reduced risk of anaemia and stunting and increased achievement of motor development. After adjusting for age, infants exposed to MNPs had a higher likelihood of standing alone (AOR = 3.1; 95% CI [1.53, 6.46]) and walking alone (4.9; 95% CI [2.12, 11.37]) than unexposed ones. Exposure to MNPs, DDS, stunting, and mothers education were associated with acquisition of motor development milestones. Provision of low-iron dose MNPs on alternate days is associated with lower prevalence of anaemia, stunting, and increased motor development achievements. Integrating routine monitoring of motor development milestones with growth monitoring and anaemia screening can inform nutrition interventions to support optimal brain development.

Exploring barriers and enablers for scaling up a community-based grain bank intervention for improved infant and young child feeding in Ethiopia: A qualitative process evaluation.

Child malnutrition remains high in Ethiopia, and inadequate complementary feeding is a contributing factor. In this context, a community-based intervention was designed to provide locally made complementary food for children 6-23 months, using a bartering system, in four Ethiopian regions. After a pilot phase, the intervention was scaled up from 8 to 180 localities. We conducted a process evaluation to determine enablers and barriers for the scaling up of this intervention. Eight study sites were selected to perform 52 key informant interviews and 31 focus group discussions with purposely selected informants. For analysis, we used a framework describing six elements of successful scaling up: socio-political context, attributes of the intervention, attributes of the implementers, appropriate delivery strategy, the adopting community, and use of research to inform the scale-up process. A strong political will, alignment of the intervention with national priorities, and integration with the health care system were instrumental in the scaling up. The participatory approach in decision-making reinforced ownership at community level, and training about complementary feeding motivated mothers and women's groups to participate. However, the management of the complex intervention, limited human resources, and lack of incentives for female volunteers proved challenging. In the bartering model, the barter rate was accepted, but the bartering was hindered by unavailability of cereals and limited financial and material resources to contribute, threatening the project's sustainability. Scaling up strategies for nutrition interventions require sufficient time, thorough planning, and assessment of the community's capacity to contribute human, financial, and material resources.

Complementary Feeding: Review of Recommendations, Feeding Practices, and Adequacy of Homemade Complementary Food Preparations in Developing Countries - Lessons from Ethiopia.

Breastfeeding provides the ideal food during the first 6 months of life. Complementary feeding starts when breast milk is no longer sufficient by itself, where the target age is for 6-23 months. The gap between nutritional requirement and amount obtained from breast milk increases with age. For energy, 200, 300, and 550 kcal per day is expected to be covered by complementary foods at 6-8, 9-11, and 12-23 months, respectively. In addition, the complementary foods must provide relatively large proportions of micronutrients such as iron, zinc, phosphorus, magnesium, calcium, and vitamin B6. In several parts of the developing world, complementary feeding continues as a challenge to good nutrition in children. In Ethiopia, only 4.2% of breastfed children of 6-23 months of age have a minimum acceptable diet. The gaps are mostly attributed to either poor dietary quality or poor feeding practices, if not both. Commercial fortified foods are often beyond the reach of the poor. Thus, homemade complementary foods remain commonly used. Even when based on an improved recipe, however, unfortified plant-based complementary foods provide insufficient key micronutrients (especially, iron, zinc, and calcium) during the age of 6-23 months. Thus, this review assessed complementary feeding practice and recommendation and reviewed the level of adequacy of homemade complementary foods.

Assessment of Caregiver's Knowledge, Complementary Feeding Practices, and Adequacy of Nutrient Intake from Homemade Foods for Children of 6-23 Months in Food Insecure Woredas of Wolayita Zone, Ethiopia.

Complementary feeding should fill the gap in energy and nutrients between estimated daily needs and amount obtained from breastfeeding from 6-month onward. However, homemade complementary foods are often reported for inadequacy in key nutrients despite reports of adequacy for energy and proteins. The aim of this study was to assess caregiver's complementary feeding knowledge, feeding practices, and to evaluate adequacy daily intakes from homemade complementary foods for children of 6-23 months in food insecure woredas of Wolayita zone, Ethiopia. A cross-sectional study assessing mothers/caregiver's knowledge and complementary feeding practice, adequacy of daily energy, and selected micronutrient intakes using weighed food record method. Multi-stage cluster sampling method was also used to select 68 households. Caregivers had good complementary feeding knowledge. Sixty (88.2%) children started complementary feeding at 6 months and 48 (70.6%) were fed three or more times per day. Daily energy intake, however, was significantly lower (p < 0.05) than estimated daily needs, with only 151.25, 253.77, and 364.76 (kcal/day) for 6-8, 9-11, and 12-23 months, respectively. Similarly, Ca and Zn intakes (milligrams per day) were below the daily requirements (p = 0.000), with value of 37.76, 0.96; 18.83, 1.21; 30.13, 1.96; for the 6-8, 9-11, and 12-23 months, respectively. Significant shortfall in daily intake of Fe (p = 0.000) was observed among the 6-8 and 9-11 months (3.25 and 4.17 mg/day, respectively), even accounting for high bioavailability. The complementary foods were energy dense. Daily energy, Ca, Zn, and Fe (except 12-23 months) intake, however, was lower than estimated daily requirements.