Uncovering social and environmental factors that increase the burden of climate-sensitive diarrheal infections on children.

Climate-sensitive infectious diseases are an issue of growing concern due to global warming and the related increase in the incidence of extreme weather and climate events. Diarrhea, which is strongly associated with climatic factors, remains among the leading causes of child death globally, disproportionately affecting populations in low- and middle-income countries (LMICs). We use survey data for 51 LMICs between 2000 and 2019 in combination with gridded climate data to estimate the association between precipitation shocks and reported symptoms of diarrheal illness in young children. We account for differences in exposure risk by climate type and explore the modifying role of various social factors. We find that droughts are positively associated with diarrhea in the tropical savanna regions, particularly during the dry season and dry-to-wet and wet-to-dry transition seasons. In the humid subtropical regions, we find that heavy precipitation events are associated with increased risk of diarrhea during the dry season and the transition from dry-to-wet season. Our analysis of effect modifiers highlights certain social vulnerabilities that exacerbate these associations in the two climate zones and present opportunities for public health intervention. For example, we show that stool disposal practices, child feeding practices, and immunizing against the rotavirus modify the association between drought and diarrhea in the tropical savanna regions. In the humid subtropical regions, household's source of water and water disinfection practices modify the association between heavy precipitation and diarrhea. The evidence of effect modification varies depending on the type and duration of the precipitation shock.

Impact of a Homestead Food Production Program on Dietary Diversity: Seasonal and Annual Results from the Cluster-Randomized FAARM Trial in Sylhet, Bangladesh.

BACKGROUND: Rice-predominant diets are common in Bangladesh, leading to widespread nutritional deficiencies. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Sylhet, Bangladesh evaluated a homestead food production intervention implemented 2015-2018 through Helen Keller International, aiming to improve child growth. OBJECTIVES: We estimated the intervention's impact on women's and children's dietary diversity, a secondary trial objective. METHODS: We collected dietary diversity throughout the trial (March 2015 to June 2020) at multiple times each year using standard, United Nations-endorsed, self-reported measures for women (10-food group scale) and children (7-food group scale). We included 28,282 observations of 2701 women (out of 2705 enrolled) and 17,445 observations of their 3257 children (aged 6-37 mo) in 96 settlements, 48 of which received the intervention. We estimated the intervention's impact on dietary diversity by year of intervention, overall periods following the start of the intervention, and seasonally, using multilevel regression with the control group as the counterfactual, controlling for seasonality, baseline dietary diversity, and clustering by settlement and repeated measures. RESULTS: At baseline, approximately one-third of women and children consumed a minimally diverse diet. Over the entire intervention and postintervention period, women's and children's odds of consuming a minimally diverse diet nearly doubled (odds ratio [OR] 1.8, P < 0.001, for both). This benefit was barely present in the first year, increased in the second, and peaked in the last intervention year (OR 2.4 for women, OR 2.5 for children, both P < 0.001) before settling at around double the odds in postintervention years (P < 0.001). Dietary improvement was observed throughout the year for both women and children with incremental increases in nearly all food groups. CONCLUSIONS: The nutrition-sensitive agriculture intervention successfully increased dietary diversity in women and children, and these impacts persisted after the project closed, including during the early COVID 19 lockdown period. This trial was registered at clinicaltrials.gov as NCT02505711.

Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry in Brazil.

BACKGROUND: The exploitative marketing of commercial milk formula (CMF) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the International Code of Marketing of Breast-Milk Substitutes (The Code) was adopted by WHO member states, many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, worldwide CMF markets have markedly expanded. In this paper, we adopt Brazil as a case study to understand the power of the baby food industry's marketing and corporate political activity, and how this influences the country's 'first-food system' in ways that promote and sustain CMF consumption. METHODS: We used a case study design, drawing data from from documents and key informant interviews (N = 10). RESULTS: Breastfeeding rates plummeted in Brazil to a historic low in the 1970s. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national policy framework and breastfeeding protection law, resulting in-turn, from collective actions by breastfeeding coalitions, advocates, and mothers. Yet more recently, improvements in breastfeeding have plateaued in Brazil, while the industry grew CMF sales in Brazil by 750% between 2006 and 20. As regulations tightened, the industry has more aggressively promoted CMF for older infants and young children, as well as specialised formulas. The baby food industry is empowered through association with powerful industry groups, and employs lobbyists with good access to policymakers. The industry has captured the pediatric profession in Brazil through its long-standing association with the Brazilian Society of Pediatrics. CONCLUSION: Brazil illustrates how the baby food industry uses marketing and political activity to promote and sustain CMF markets, to the detriment of breastfeeding. Our results demonstrate that this industry requires much greater scrutiny by regulators.

Promoting responsive care and early learning practices in Northern Ghana: results from a counselling intervention within nutrition and health services.

OBJECTIVE: This study assesses change in caregiver practices after integrating responsive care and early learning (RCEL) in nutrition and health services and community platforms in northern Ghana. DESIGN: We trained health facility workers and community health volunteers to deliver RCEL counselling to caregivers of children under 2 years of age through existing health facilities and community groups. We assessed changes in caregivers' RCEL practices before and after the intervention with a household questionnaire and caregiver-child observations. SETTING: The study took place in Sagnarigu, Gushegu, Wa East and Mamprugu-Moagduri districts from April 2022 to March 2023. Study sites included seventy-nine child welfare clinics (CWC) at Ghana Health Service facilities and eighty village savings and loan association (VSLA) groups. PARTICIPANTS: We enrolled 211 adult caregivers in the study sites who had children 0-23 months at baseline and were enrolled in a CWC or a VSLA. RESULTS: We observed improvements in RCEL and infant and young child feeding practices, opportunities for early learning (e.g. access to books and playthings) in the home environment and reductions in parental stress. CONCLUSIONS: This study demonstrates the effectiveness of integrating RCEL content into existing nutrition and health services. The findings can be used to develop, enhance and advocate for policies integrating RCEL into existing services and platforms in Ghana. Future research may explore the relationship between positive changes in caregiver behaviour and improvements in child development outcomes as well as strategies for enhancing paternal engagement in care practices, improving child supervision and ensuring an enabling environment.

Commercial milk formula marketing entry points: setting the course of infant and young child feeding trajectories.

BACKGROUND: There is a limited understanding of the dynamic influences that shape infant and young child feeding (IYCF) decisions over time. We conducted an innovative qualitative study to reconstruct IYCF trajectories across early life course phases, in the context of the socioecological model (SEM) and the commercial determinants of IYCF. METHODS: Women of different socioeconomic status were interviewed in two large metropolitan areas in Mexico. Our specific goal was to allow us to better understand if and how the commercial milk formula (CMF) marketing influenced breastfeeding decisions in a complex dynamic way involving the individual, relational, community and societal levels. RESULTS: Hospitals, health professionals, and interactions with social media were key category entry points throughout the prenatal, perinatal, early infancy period and beyond. The CMF industry interfered by engaging a wide array of actors across the different layers of the SEM, most prominently the health care system and the workplace. Through its marketing strategies the CMF operates subconsciously and its messages are most effective when health institutions, health care providers, workplace spaces and social norms are weak in their support for breastfeeding. CONCLUSIONS: The cases in our study highlight how, together with a weak breastfeeding counseling system, and health professionals who lack training in breastfeeding and normal infant behavior, lead to the opportunity for CMF marketing to shape infant feeding, and ultimately to the decision to feed formulas that some mothers were not planning to use and cannot afford.

The potential effectiveness of community health and nutrition volunteers on mothers' infant and young children feeding knowledge and practice in remote areas, Hajjah, Yemen.

BACKGROUND: The Infant and young child feeding (IYCF) practices directly affect the health, development and nutritional status of children under two years of age. However, IYCF counseling is one of the Community Health and Nutrition Volunteers (CHNVs) activities provided, which may contribute to improving the IYCF knowledge and practice among mothers. Since establishment of the CHNVs program in Yemen, its outcome has never been evaluated. Therefore, the aim of this study was to evaluate the role of CHNVs in improving the IYCF knowledge and practice among mothers in Hajjah governorate. METHODS: A comparative cross-sectional study design was conducted in Bani Qais and Al-Maghrabah districts, Hajjah governorate between January and April 2023. A three-stage cluster sampling method was used to select districts, volunteer villages and households. A total of 926 mothers were interviewed. A pre-tested structured questionnaire was used to collect data. SPSS 26 was used for data analysis. The multinomial logistic regression and Chi-Square test were used to compare the IYCF knowledge and practices among mothers between the volunteer and non-volunteer villages. Odds Ratio (OR) with 95% Confidence Interval (CI) were calculated. A p-value < 0.05 was considered statistically significant. RESULTS: The mothers in volunteer villages had significantly better breastfeeding and complementary feeding (CF) knowledge than mothers in non-volunteer villages. The OR of having good and moderate knowledge of breastfeeding were 3.5 (95%CI: 2.4-5.2) and 1.6 (95% CI: 1.2-2.2), respectively. The OR for good and moderate knowledge of CF were 1.7 (95% CI: 1.1-2.7) and 2.2 (95% CI: 1.5-3.0), respectively. Moreover, there is a statistically significant association in prevalence of Exclusively breastfed for the first two days after birth (EBF2D), Mixed milk feeding under six months (MixMF) and Bottle feeding 0-23 months (BoF) between volunteer and non-volunteer villages [(OR = 1.4, 95% CI: 1.0-1.8), (OR = 0.4, 95% CI: 0.2-0.8) and (OR = 0.5, 95% CI: 0.4-0.7), respectively]. CONCLUSIONS: The study found that CHNVs play a significant effect in improving the breastfeeding and CF knowledge, and prevalence of EBF2D, MixMF and BoF practices among mothers in their villages compared to non-volunteer villages. Future follow-up study and expansion to other settings in different governorates is recommended.

Influences in food selection during complementary feeding in breastfeeding infants: A systematic review and metasynthesis of qualitative studies.

In the transition period from breastfeeding to the introduction of complementary feeding, the choice of food is extremely important for the child's development as many factors may be related. This study aims to investigate, through a systematic review and qualitative meta-synthesis, influence in the selection of foods in the introduction of complementary foods for children, including qualitative studies without language or publication period restrictions. Searches were performed in PubMed, LILACS, SciELO, Cinahl, Embase, Web of Science, and Scopus. Initially, 12,489 articles were selected for tittle reading, 13 were included in the review. Four analytical themes related to factors influencing complementary feeding were identified: family socioeconomic conditions, cultural and family aspects, guidance and advice from health professionals, and factors inherent to the infant. Economic factors, such as the opportunity to offer foods not consumed during the parents' childhood, were emphasized. The influence of grandmothers' opinions and community beliefs and traditions were considered. Trust in pediatricians and community health agents' advice, although considered, conflicted with cultural and family traditions. Mothers/caregivers often preferred to offer foods the child shows preference for, rather than introducing new flavors. The findings underscore the need for a better understanding of qualitative aspects.

The longitudinal association between caregivers' perceived competence and autonomy and children's dietary consumption before and 10 months into the COVID-19 pandemic.

The COVID-19 pandemic has been stressful, potentially affecting caregivers' feeding choices. Caregivers play a role in shaping children's diets, yet few studies have explored how their competence and autonomy, defined by the Self-Determination Theory, impact children's diets. We examined the relationship between caregivers' autonomy and competence and their feeding practices before and during the first year of the pandemic. A national convenience sample of caregivers with 3-12-year-old children completed an online survey during two time-periods. Questions adapted from the Intrinsic Motivation Inventory measured perceived competence and autonomy for feeding fruits and vegetables (F/V) and limiting sugar-sweetened beverages (SSBs) and desserts. National Health and Nutrition Examination Survey Dietary Screener questions measured children's consumption of F/V, SSBs, and desserts. Paired t-tests examined how child consumption and caregiver's perceived competence and autonomy changed, and logistic regressions examined whether caregivers' competence and autonomy predicted the change in child consumption and if changes in competence and autonomy were associated with changes in child consumption. Caregivers (n = 597) were mostly Black/African American (33.0%) or Latina/o/x (42.7%) and older than 30 years (84.1%). Children's consumption did not change overall, but caregivers' competence for feeding F/V increased, and their competence for limiting SSBs and desserts decreased. Caregiver competence and autonomy before COVID-19 did not predict child dietary consumption during the pandemic. However, change in competence was a significant predictor of the change in child consumption of F/V [OR (95%CI): 0.70 (0.57, 0.86)]. The association between caregiver's perceived competence for feeding F/V and child consumption remained positive and significant in both periods [OR (95%CI) pre and during COVID: 2.09 (1.69, 2.57) - 2.40 (1.88, 3.06)]. This study can inform behavioral interventions supporting caregivers' competence and autonomy around feeding choices.

The role of food reward in the associations between weight-based discrimination and feeding practices among caregivers of young children.

Certain caregiver feeding practices, including restrictive feeding for weight control, restrictive feeding for health, emotion regulation feeding, and reward feeding, are known to negatively influence short- and long-term child eating and health outcomes. Beyond body size, the precise psychosocial characteristics of caregivers more likely to engage in such feeding practices are unknown. In particular, caregivers who have experienced discrimination based on their weight, who have internalized those biased beliefs, or who find food to be very rewarding may be more likely to use restrictive or controlling feeding practices. The present study investigated the associations among experiences of weight-based discrimination, internalized weight bias, and food reward (i.e., reward-based eating drive) with use of restriction for weight control, restriction for health, emotion regulation feeding, and reward feeding in an online US sample of caregivers (M = 35.27 ± 9.08 y/o) of 2-5 year-old children (N = 305). About half (50.8%) of respondents self-identified as women and most as non-Hispanic (88.5%) and White (75.1%). There were significant positive correlations among caregivers' experience of weight-based discrimination, internalized weight bias, and use of all four feeding practices. Regression results showed that caregivers' food reward moderated the main effect of weight-based discrimination on restrictive feeding for weight control and emotion regulation feeding, such that caregivers who were high in food reward and who experienced discrimination were most likely to engage in these feeding practices. These results can inform interventions aimed at improving child food environments and health.

Fathers' use of social media for social comparison is associated with their food parenting practices.

Over 85% of parents use social media; however, limited research has investigated the associations between parental social media use and food parenting practices. The objectives of this study were to: 1) describe how mothers and fathers use social media focused on topics related to child feeding and family meals; and 2) examine associations between parental social media use focused on child feeding and family meals and mothers' and fathers' food parenting practices. Data were obtained from 179 mothers and 116 fathers of children aged 3-8 years enrolled in a family-based obesity prevention intervention. We used descriptive statistics to describe parents' social media use in relation to child feeding and family meals and linear regressions with generalized estimating equations to explore associations between parents' social media use and food parenting practices. Models were stratified by parent gender and adjusted for household income, parent ethnicity, parent age, child sex, and intervention status. A higher percent of mothers than fathers reported using social media to seek information related to child feeding and family meals (64.8% mothers; 25.0% fathers) and to share and compare family meals and food choices (41.9% mothers; 19.8% fathers). While social media use was not associated with food parenting practices in mothers, fathers' social media use to share and compare family meals and food choices was associated with negative food parenting practices, i.e., greater use of food for emotional regulation (ß = 0.37, p = 0.02) and greater use of food for reward (ß = 0.34, p = 0.02). Study results can inform strategies to promote healthy social media use among parents of young children.

The temporal stability of maternal parenting style and child feeding practices: A six-wave longitudinal study.

Although parenting styles and child feeding practices are conceptualized as distal, static predictors of child eating and weight outcomes, few studies have examined the temporal stability (i.e., change over time) of these parenting measures. Also, parental characteristics, such as mental health or socio-demographics, may make it more or less difficult to sustain consistent parenting behavior. This study examined the temporal stability of parenting styles and child feeding practices and the association between temporal stability indices with maternal sociodemographic and mental health characteristics. The analytic sample included 161 ethnically diverse mothers enrolled in a six-wave bi-annual longitudinal study. During each wave, mothers reported on their parenting styles and child feeding practices using validated self-report questionnaires. Temporal stability indices for parenting styles were moderate for authoritative (ICC = 0.57) and authoritarian (ICC = 0.70) styles, yet high for permissive (ICC = 0.78) styles. Temporal stability scores for child feeding practices were low for discipline (ICC = 0.33), limit setting (ICC = 0.33), monitoring (ICC = 0.36), and pressure to eat (ICC = 0.34); however, restriction (ICC = 0.53) and role modeling of healthy eating were moderate (ICC = 0.73). Greater income and education status were positively associated with stability in authoritative, authoritarian, and permissive parenting styles, as well as with limit setting, monitoring, role modeling of healthy eating, and pressure to eat feeding practices. Higher anxiety and depressive symptoms and lower self-esteem were negatively associated with permissive parenting styles and role modeling of healthy eating. Findings show that maternal parenting styles and child feeding practices fluctuate over time, and sociodemographic and mental health characteristics are related to stability of some of these parenting styles and behaviors.

A Mobile Gaming App to Train Teenage Mothers on Appropriate Child Feeding Practices: Development and Validation Study.

BACKGROUND: Undernutrition is an underlying factor in nearly 50% of 1 million estimated annual deaths among Nigerian children aged <5 years. Inappropriate maternal infant and young child feeding (IYCF) practices are basic contributors to child undernutrition. Teenage motherhood exacerbates the problem of inadequate child feeding. One possible intervention method to improve IYCF knowledge and practices of teenage mothers is the use of mobile gaming technologies. Despite extreme poverty in low- and middle-income countries, a ubiquity of mobile phone networks exists. OBJECTIVE: This study aims to develop and validate a mobile gaming app, called BabyThrive, to train Nigerian teenage mothers on appropriate IYCF practices. METHODS: To identify gaps in current IYCF practices in northern Nigeria, we conducted an extensive search of the literature and held 2 focus group interviews with 16 teenage mothers with low-income status. An initial app content design was then created, and content validity was established by 10 nutrition experts. Next, we developed an app prototype, which was assessed for quality by 7 nutrition and mobile gaming experts and evaluated for usability by 90 teenage mothers from rural areas in Abuja, the country's capital. The final app, BabyThrive, is a 2D mobile game that is fully functional offline and available in English as well as Hausa, which is commonly spoken in northern Nigeria. The efficacy of the BabyThrive app was assessed using IYCF knowledge scores obtained from the administration of the validated Teen Moms Child Feeding Questionnaire for Sub-Saharan Africa. Construct validity was established via crossover design by comparing the total IYCF knowledge scores of the teenage mothers obtained after a verbal training program and BabyThrive app use. RESULTS: Large proportions of the study participants were married (53/90, 59%) and had no personal income (63/90, 70%). The mean quality rating for the BabyThrive app was 4.3 (SD 0.39) out of 5.0. High levels (>80%) of usability and user satisfaction were documented. Knowledge of exclusive breastfeeding (P<.001) and total knowledge scores (P=.002) were significantly higher in the BabyThrive group than in the verbal training group. The IYCF knowledge scores obtained from both groups showed coherence, with a statistically significant Spearman correlation coefficient of 0.50 (P<.001). CONCLUSIONS: This research developed and validated a novel, offline mobile gaming app. It will be an easy, effective, and acceptable method to disseminate critical knowledge on IYCF practices to teenage mothers in rural Nigeria.

Factors associated with infant and young child feeding practices in children aged 6-23 months in Indonesia: A nationwide study.

INTRODUCTION: Children-related nutrition raises significant attention due to the low implementation of infant and young child feeding (IYCF) practices. However, the factors affecting the low implementation of IYCF remains limited globally. This study aimed to identify factors influencing IYCF in children aged 6-23 months in Indonesia. METHODS: We conducted a cross-sectional study using data from the 2017 Indonesian Demographic and Health Survey. A total of 4943 responses were included. We employed binary logistic regression to determine the factors affecting IYCF practices in children aged 6-23 months. The results are reported as odds ratios (OR) with a 95% confidence interval (CI) and a significance level of p < 0.05. RESULTS: Several factors significantly influenced IYCF practices among children aged 6-23 months, including the age of the child (OR: 0.42; 95% CI: 0.27-0.65), middle wealth index (OR: 1.85; 95% CI: 1.12-3.08), regional disparities (OR: 0.43; 95% CI: 0.23-0.77), place of residence (OR: 1.77; 95% CI: 1.17-2.68), and a history of childhood diseases like fever (OR: 1.65; 95% CI: 1.05-2.58). CONCLUSION: This study highlights the significance of various factors related to IYCF practices among children aged 6-23 months. These factors include maternal aspects such as wealth index, child-related factors like age, a history of childhood illnesses such as fever, and environmental factors such as regional disparities and place of residence. PRACTICE IMPLICATIONS: Paediatric nurses can contribute to enhancing maternal knowledge by providing education on the importance of infant and child feeding practices, beginning early in the child's life.

Effectiveness of a food literacy and positive feeding practices program for parents of 0 to 5 years olds in Western Australia.

ISSUE ADDRESSED: Lifelong eating behaviours are established in childhood. Improving parents' food literacy skills is essential, as parents play a fundamental role in establishing their children's healthy eating behaviours and preferences for nutritious food. This paper describes the development and evaluation of an innovative program that combines food literacy with positive parent feeding practices, targeting parents in disadvantaged areas of Western Australia. METHODS: The Food Sensations® for Parents five-week program was delivered to participants from community-based parenting organisations during 2020 and 2021. Formative research and a pre-post evaluation design were adopted. RESULTS: Pre- and post-evaluation data were collected from 224 participants (96% female). There was a statistically significant improvement in the mean score for 13 food literacy behaviours, 10 positive parenting feeding practices and a mean increase in parents' daily vegetable intake of 1/3 serve. Participants reported significantly greater net improvements in food literacy behaviours than feeding practices, the largest being the Use a nutrition information panel to make food choices (33.1%). Multivariate logistic regression analyses found English as a first language, being older than 35, and from a higher Socio-Economic Index for Areas resulted in a higher likelihood of positive changes in behaviours and practices. CONCLUSIONS: The findings indicate that the program is effective in improving the frequency of use of food literacy behaviours, positive parenting feeding practices and increasing vegetable consumption. SO WHAT?: Analysing improvements in food literacy behaviours and feeding practices provides clarity on what change can be expected with a five-week parent program.

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

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

Associations between food insecurity and child and parental physical, nutritional, psychosocial and economic well-being globally during the first 1000 days: A scoping review.

Food insecurity affects billions of individuals annually and contributes to myriad poor health outcomes. Experiences of food insecurity may be particularly harmful during the first 1000 days, but literature on the topic has not been synthesized. We therefore aimed to characterize all available studies examining associations between food insecurity and nutritional, psychosocial, physical and economic well-being among parents and children during this period. We implemented a standardized search strategy across 11 databases. Four researchers screened 10,257 articles, 120 of which met the inclusion criteria. Most studies were conducted in Sub-Saharan Africa (43.3%), followed by North America (20.8%). Studies were primarily quantitative (95.8%), cross-sectional (70.0%) and focused on women (pregnant or post-partum, 48.3%) or women and children (15.8%). Physical health outcomes were the most investigated (n = 87 studies), followed by nutritional (n = 69), psychosocial (n = 35) and economic well-being (n = 2). The most studied associations were between food insecurity and stunting (n = 15), maternal depression (n = 12), child dietary diversity (n = 7) and maternal body mass index (n = 6). The strength of evidence for the observed associations varied across populations as well as within and between examined outcomes. We recommend that future studies recruit more diverse study populations, consider temporality of relationships, use instruments that facilitate cross-site comparisons, measure individual-level food insecurity and outcomes most likely to be impacted by food insecurity, evaluate contextual factors that may modify the effects of food insecurity and employ analytic techniques that permit assessment of causal pathways.

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.

Associations of fish and meat intake with iron and anaemia in Malawian children.

Animal flesh foods are rich in bioavailable iron but infrequently consumed by young children. We aimed to determine whether flesh food intake was associated with iron and anaemia status among 585 Malawian infants enroled in a 6-month egg-feeding trial. The percentage of days of small fish, large fish and meat consumption were assessed through weekly 7-day animal-source food screeners. Grams of intake were assessed through 24-h recalls conducted at 6-9, 9-12 and 12-15 months of age. Plasma ferritin, soluble transferrin receptor (sTfR) and haemoglobin concentrations were measured at 6-9 and 12-15 months of age. Iron biomarkers were adjusted for inflammation during analysis. At enrolment, each flesh food category was consumed by <5% of children in the past 24 h. Over the next 6 months, small fish, large fish and meat were consumed on 25%, 8% and 6% of days, respectively, with mean usual intakes of <5 g/day. More frequent small fish consumption was associated with lower sTfR (geometric mean ratio [95% CI]: 0.98 mg/L [0.96, 1.00] per 10 percentage point difference) but not ferritin (1.03 µg/L [0.98, 1.07]) or haemoglobin (1.01 g/dL [1.00, 1.01]). Large fish consumption was associated with higher anaemia (prevalence ratio [95% CI]: 1.09 [1.01, 1.19]) and lower iron deficiency (0.96 [0.93, 1.00]) prevalence. Gram intakes of flesh food categories were not associated with any iron or anaemia indicators. Small fish were a primary contributor to flesh food intake in this cohort of Malawian children, although usual portions were small. Fish was associated with modest improvements to iron status, but meat was too infrequent to be associated with anaemia and iron deficiency.

Infant and young child feeding practices in refugee settings across 203 population-based surveys from 2013-2019.

Infant and young child feeding (IYCF) plays a crucial role in early childhood growth and development. This study summarizes recent IYCF practices in multiple refugee settings and compares them to those in the host countries. We analyzed 203 surveys conducted among refugees residing in 15 countries and 120 unique sites and assessed eight IYCF indicators available from those surveys. A total of 146 surveys were conducted in Eastern and Southern Africa (ESA) and 50 in Western and Central Africa (WCA) regions. The median prevalence across surveys of all four indicators describing intake of breast milk was relatively high: 96.6% for ever breastfed, 81.2% for initiation of breastfeeding within 1 h of birth, 76.9% for exclusive breastfeeding 0-5 months, and 75.0% for continued breastfeeding 12-23 months. The median prevalence of early initiation and exclusive breastfeeding was markedly higher in ESA than in WCA (85.0% vs. 37.5% and 83.5% vs. 56.1%, respectively). Conversely, the overall median prevalence of timely introduction of solid and semisolid foods and flesh food consumption was low: 51.8% and 16.1%, respectively. Flesh food consumption was higher in WCA than in ESA (27.4% vs. 11.6%). The median prevalence of mixed milk feeding at 0-5 months and bottle feeding was very low: 2.4% and 3.8%, respectively. Indicators describing breast milk intake were generally either similar or higher in refugees than in the host country populations, whereas the other indicators were generally higher in the host populations than in refugees. The low prevalence of timely introduction of solids and of flesh food consumption in refugees is concerning and requires substantial improvement.

Infant and young child feeding indicators are positively associated with length and family care indicators in the children of the Women First trial participants.

This research describes the proportion of children in four low- and middle-income countries with adequate dietary practices at 6, 12, 18 and 24 months of age and how these practices changed over time using the World Health Organisation and UNICEF's infant young child feeding (IYCF) indicators. The associations between the IYCF indicators and anthropometric z-scores from 6 to 24 months, and between the IYCF indicators and the family care indicators (FCIs) at 24 months are described. This was a longitudinal study of offspring from participants in the Women First Preconception Maternal Nutrition Trial conducted in Sud-Ubangi, Democratic Republic of Congo; Chimaltenango, Guatemala; Belagavi, North Karnataka, India; and Thatta, Sindh Province, Pakistan. The frequency of the minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum adequate diet (MAD) increased between 6 and 24 months, but even at 24 months MAD remained below 50% at all sites. MDD (ß = 0.12; 95% CI = 0.04-0.22) and MMF (ß = 0.10; 95% CI = 0.03-0.17) were positively associated with length-for-age z-score at 24 months. All IYCF indicators were positively associated with mean total FCI score: MDD (proportion ratio [PR] = 1.04; 95% CI = 1.02-1.07), MMF (PR = 1.02; 95% CI = 1.01-1.04), MAD (PR = 1.05; 95% CI = 1.02-1.08). Although there are multiple barriers to young children having an adequate diet, our results support a positive association between familial interactions and improved IYCF feeding practices.