High consumption of unhealthy commercial foods and beverages tracks across the complementary feeding period in rural/peri-urban Cambodia.

Consumption of unhealthy commercial foods and beverages (UCFB) is common among infants and young children living in low- and middle-income countries. Such foods can displace other nutritious foods, however, there is limited evidence on how this consumption tracks across time. This study assessed and tracked UCFB consumption of children living in rural/peri-urban Cambodia during the complementary feeding period, identified UCFB consumption patterns of these children, and explored the association between UCFB consumption and growth. A 6-month longitudinal cohort study was implemented among 567 caregivers of children aged 10-14 months at recruitment. UCFB consumption was estimated each month via a telephone-administered 7-day food frequency questionnaire, and UCFB consumption patterns were identified based on changes in this frequency of consumption over time. The majority of children either maintained (45.7%, n = 246) or developed (43.5%, n = 234) an unhealthy consumption pattern and only 10.8% (n = 58) of children maintained/transitioned into a healthy consumption pattern. High consumers of UCFB at 10-14 months had a 4.7 (CI: 4.7 [3.1-7.2]) times odds of being high consumers of UCFB at 15-19 months (p < 0.001). There was a trend of lower length-for-age z-scores (LAZ) among children maintaining or developing an unhealthy consumption pattern (~-0. SD LAZ) compared to children maintaining/transitioning into a healthy consumption pattern, however, this association was not statistically significant. Findings indicate that high UCFB consumption begins during infancy and tracks into early childhood. National policies and programmes centred on early interventions addressing the use of UCFB for infant and young child feeding are needed.

Benchmarking the nutrient composition and labelling practices of dry or instant cereals for older infants and young children across seven Southeast Asian countries.

In Southeast Asia, the increasing availability of commercially produced complementary foods (CPCF), including dry or instant cereals (CPCF cereals), has been noted, however, concerns exist around their nutrient profile and labelling practices. This 2021 study assessed the nutrient composition, labelling practices, and micronutrient content of CPCF cereals sold in the capital cities of seven Southeast Asian countries: Phnom Penh (Cambodia), Jakarta (Indonesia), Manila (Philippines), Bangkok (Thailand), Vientiane (Lao PDR), Hanoi (Vietnam), and Kuala Lumpur (Malaysia). The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older infants and young children. Micronutrient content of fortified CPCF cereals was assessed against fortification levels specified in the Codex Alimentarius guideline for formulated complementary foods. Of the 484 products assessed, 184 (38.0%) met all nutrient composition requirements. Around one-third of CPCF cereals contained added sugars and/or sweeteners (37.2%) and high levels of sodium (28.9%). None of the CPCF cereals met all labelling requirements, primarily due to the presence of inappropriate claims on the labels. Most fortified CPCF cereals contained adequate amounts of critical micronutrients, such as calcium, iron, zinc, vitamin A, and vitamin D. However, rates of fortification varied across the seven countries, and almost a third (30.8%) of CPCF cereals were not fortified with any micronutrients. To support the appropriate promotion of CPCF in the region, Southeast Asian countries need to strengthen and enforce national binding legal measures, including national standards for the composition, labelling, and fortification of CPCF cereals.

Benchmarking the nutrient composition and labelling practices of commercially produced ready-to-eat purées and meals for older infants and young children across seven Southeast Asian countries.

Commercially produced complementary foods (CPCF), including ready-to-eat CPCF purées and meals, are gaining popularity among caregivers of older infants and young children (IYC) as a convenient alternative to home-prepared foods in low and middle-income countries. However, there is growing concern regarding the suitability of these products for older IYC, as they can contain high levels of sugar and/or sodium. Given the rapidly evolving market in Southeast Asia, it is crucial to monitor the appropriate composition and promotion of CPCF in the region. This study examined the nutrient composition and labelling practices of CPCF purées and meals sold in 2021 in the capital cities of seven Southeast Asian countries: Phnom Penh (Cambodia), Jakarta (Indonesia), Manila (Philippines), Bangkok (Thailand), Vientiane (Lao PDR), Hanoi (Viet Nam), Kuala Lumpur (Malaysia). The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older IYC. The proportion of CPCF purées and meals that would require a high sugar front-of-pack warning based on the percentage energy from total sugar was also determined. Of the 459 CPCF purées/meals assessed, only 37.7% of the products met all nutrient composition requirements and none met all labelling requirements. In addition, most CPCF purées and meals were identified as having high total sugar content. To ensure that older IYC consume appropriate CPCF products, Southeast Asian countries need to implement and enforce regulations concerning the nutrient composition and labelling practices of CPCF purées and meals.

Benchmarking the nutrient composition and labelling practices of finger foods and snacks for older infants and young children across seven Southeast Asian countries.

Ensuring consumption of nutrient-dense, safe and appropriate complementary foods among older infants and young children (IYC) 6-36 months of age is critical for enabling optimal growth and development. The ubiquitous availability of and high demand for commercially packaged snack foods has culminated in a growing trend of snack food products specifically produced and promoted for older IYC. Commercially produced complementary foods (CPCF) that are finger foods/snacks often contain added sugars, excessive sodium content and high total sugar content, making them inappropriate for this young population. This study benchmarked the nutrient composition and labelling practices of CPCF finger foods/snacks available for purchase in seven countries in Southeast Asia. The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older IYC. Of the total 606 products identified, 8.2% were automatically categorized as not suitable because they were confectionery items. Of the remaining 556 products assessed, over 85% failed to meet all nutrient composition requirements, with the presence of added sugars/sweeteners and excessive sodium and total sugar contents the primary reasons for failure. Products also demonstrated concerning labelling practices, with all of the products (98.6%) displaying an inappropriate claim on the label. These findings reveal major concerns with the nutrient composition and labelling practices of CPCF finger foods/snacks in the SEA region and should serve as an alarm bell for regulatory action. National binding legal measures, such as mandatory standards for composition and labelling are urgently needed.

Accuracy of declared nutrient content on labels of commercial complementary food products in Cambodia, Indonesia and Senegal.

Commercially produced complementary foods (CPCF) have the potential to fill nutritional gaps in the diets of older infants and young children. This study evaluated the accuracy of nutrient declarations on labels of 43 commonly available CPCF in three peri-urban/urban locations: Khsach Kandal district, Cambodia (n = 11); Bandung, Indonesia (n = 11) and Guédiawaye and Dakar departments, Senegal (n = 21). Label values (LV) from product nutrient declarations were compared to analytical values (AV) derived from laboratory nutrient analysis for macronutrients (carbohydrate, protein and total fat), nutrients of public health concern (saturated fat, total sugar and sodium), and micronutrients of interest (calcium, iron and zinc). European Union guidance for nutrition label accuracy was used to set tolerance ranges for each nutrient LV relative to AV. LV were missing for one or more nutrients in 88.4% (n = 38) of the CPCF products and no CPCF met EU tolerance thresholds for all nine nutrients assessed. Over half of products with LV for key micronutrients (55.6%, n = 10/18) and macronutrients (54.8%, n = 23/42) met tolerances for LV accuracy. Eighty-five percent (n = 11/13) of products with LV for nutrients of public health concern were determined to be accurate. Nutrient content claims for iron appeared on 19 (44.2%) of the 43 products. Of the products which made an iron content claim, 26.3% had inaccurate LV with the majority of these containing less iron than declared. Regulatory action is needed to ensure that CPCF labelling communicates complete and accurate nutrient content information that enables caregivers to make informed decisions for feeding older infants and young children.

Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines.

OBJECTIVE: To assess the nutritional suitability of commercially produced complementary foods (CPCF) marketed in three South-East Asian contexts. DESIGN: Based on label information declared on the products, nutrient composition and content of CPCF were assessed against the WHO Europe nutrient profile model (NPM). The proportion of CPCF that would require a 'high sugar' warning was also determined. SETTING: Khsach Kandal district, Cambodia; Bandung City, Indonesia; and National Capital Region, Philippines. PARTICIPANTS: CPCF products purchased in Cambodia (n 68) and Philippines (n 211) in 2020, and Indonesia (n 211) in 2017. RESULTS: Only 4·4 % of products in Cambodia, 10·0 % of products in Indonesia and 37·0 % of products in the Philippines fully complied with relevant WHO Europe NPM nutrient composition requirements. Sixteen per cent of CPCF in Cambodia, 27·0 % in Indonesia and 58·8 % in the Philippines contained total sugar content levels that would require a 'high sugar' warning. CONCLUSIONS: Most of the analysed CPCF were not nutritionally suitable to be promoted for older infants and young children based on their nutrient profiles, with many containing high levels of sugar and sodium. Therefore, it is crucial to introduce new policies, regulations and standards to limit the promotion of inappropriate CPCF in the South-East Asia region.

Breastfeeding and breastmilk substitute use and feeding motivations among mothers in Bandung City, Indonesia.

Suboptimal breastfeeding is common in Indonesia, with only half of infants 0-5 months of age exclusively breastfed and feeding of breastmilk substitutes (BMS) highly prevalent among infants and toddlers. Various factors influence these feeding practices, including social norms, limited health system support and BMS manufacturer marketing practices. This cross-sectional survey aimed to identify the prevalence of breastfeeding and BMS feeding among children aged 0-35 months, explore socio-demographic characteristics and motivating factors associated with these feeding behaviours and identify the prevalence of mothers' exposure to BMS promotions. Indonesian mothers of children <3 years of age (n = 595) were interviewed in Bandung City health facilities using structured questionnaires. Although all children were ever breastfed, half of children across all age groups received BMS in the previous day. Maternal employment outside the home and insufficient breastmilk production were associated with BMS use. The most important motivational factors for feeding BMS were perceived benefits for growth, intelligence and immunity. Despite Indonesian legislation restricting some BMS marketing, 93% of mothers reported observing a BMS promotion outside the health system, with television, social media and newspapers as the most common sources. Half of mothers (43%) reported observing a BMS promotion within the health system, and half (46%) reported receiving recommendations from health workers to use BMS. Such high prevalence of BMS marketing may be influencing caregivers' feeding choices; stronger national legislation and implementation of laws are needed to ensure mothers' ability to make feeding choices free from manufacturer influence.

Sugar content and nutrient content claims of growing-up milks in Indonesia.

'Growing-up milks' (GUMs)-breast-milk substitutes targeted for young children (aged 12-36 months)-are commonly consumed in Indonesia. The World Health Assembly has stated that GUMs are not necessary for proper growth and development, and recently, the American Academy of Pediatrics declared that such products are not recommended for young children due to their common use of sweeteners. To contribute to the evidence base on the composition of GUMs and their appropriateness for young child diets, this cross-sectional study documented the declared sugar content and presence of nutrient content claims of 99 GUMs newly launched in Indonesia between January 2017 and May 2019. Sugar content was evaluated against the draft 2018 Codex Alimentarius Standard for Follow-Up Formula guidance on sugar content and the United Kingdom Food Standard Agency's front-of-pack (UK FSA FOP) colour coding system for sugar. Almost all (97%) GUMs contained one or more added sugars. None of the products were fully compliant with all three sugar content recommendations in the draft Codex standard. Seventy-one per cent of GUMs were determined to have high sugar content according to the UK FSA FOP system. Nutrient content claims were found on 97% of GUMs. Median total sugar content was 7.3 g per 100 ml, similar to sugar content levels in sugar-sweetened beverages. Many GUMs available in Indonesia claim to offer nutritional benefits; however, the current levels of sugar content in GUMs are a serious concern and are inappropriate for inclusion in the diets of young children.

Unhealthy Snack Food and Beverage Consumption Is Associated with Lower Dietary Adequacy and Length-for-Age z-Scores among 12-23-Month-Olds in Kathmandu Valley, Nepal.

BACKGROUND: Consumption of unhealthy snack foods and beverages (USFBs) in low- and middle-income countries (LMICs) is rising, with global awareness increasing about risks of overnutrition. However, little is known about the relation between USFB consumption and young children's diet/nutritional outcomes in contexts where nutrient density of complementary foods is often low. OBJECTIVES: This study assessed the association of high USFB consumption, compared with low consumption, with nutrient intakes, dietary adequacy, iron status, and growth in young children in Kathmandu Valley, Nepal. METHODS: A cross-sectional survey was conducted in a representative sample of 745 primary caregivers of children aged 12-23 mo. Food consumption was measured through quantitative 24-h recalls, and child anthropometric measurements and capillary blood samples were collected. Using adjusted linear/logistic regression models, nutrient intakes, dietary adequacy, length-for-age and weight-for-length z-scores (LAZ and WLZ, respectively), and iron status were compared between lowest and highest tertiles of consumption based on the contribution of USFBs to total energy intakes (TEIs). Mediation of the relation between USFB consumption and LAZ via lowered dietary adequacy was explored using structural equations modeling. RESULTS: On average, USFBs contributed 46.9% of TEI among the highest tertile of consumers, compared with 5.2% of TEI among the lowest. Compared with low-USFB consumers, high-USFB consumers had lower nutrient intakes and a greater proportion were at risk of inadequate intakes for 8 nutrients. Mean LAZ was nearly 0.3 SD lower among high-USFB consumers than low consumers (P = 0.003), with this relationship partially mediated through dietary adequacy. No associations were found with stunting prevalence or iron status. Prevalence of overweight/obesity was low. CONCLUSIONS: In this LMIC context, high USFB consumption among young children was associated with inadequate micronutrient intakes, which can contribute to poor growth outcomes. Addressing increased availability of USFBs in LMIC food systems should be a priority for policies and programs aiming to safeguard child nutrition.

Snack food and beverage consumption and young child nutrition in low- and middle-income countries: A systematic review.

Although snacks can provide important nutrients for young children during the complementary feeding period, the increasing availability of snack foods and sugar-sweetened beverages (SSB), often energy-dense and nutrient-poor, in low- and middle-income countries (LMIC) is a concern. Such foods may displace consumption of nutritious foods in contexts where diets are often nutritionally inadequate and the burden of childhood malnutrition is high. This systematic review summarizes literature on the contribution of snack food/SSB consumption to total energy intakes (TEI) of children below 23 months of age in LMIC and associations between this consumption and nutritional outcomes. It also identifies areas where further research is needed. A systematic search of Embase, Global Health, and MEDLINE for literature published in January 1990-July 2018 was conducted. This search yielded 8,299 studies, 13 of which met inclusion criteria: Nine studies assessed % TEI from snack foods/SSB, and four studies assessed associations between snack food/SSB consumption and nutritional outcomes. Average % TEI from snack foods/SSB ranged from 13% to 38%. Findings regarding associations with growth were inconclusive, and no studies assessed associations with nutrient intakes. Variation in measurement of consumption and definitions of snack foods and SSB limited study comparisons. Further research is needed to understand how consumption of energy-dense, nutrient-poor snack foods and SSB influences undernutrition and overnutrition among young children during the complementary feeding period in settings that are experiencing dietary transitions and the double burden of malnutrition.

High proportions of children under 3 years of age consume commercially produced snack foods and sugar-sweetened beverages in Bandung City, Indonesia.

Child undernutrition continues to be a national concern in Indonesia, whereas childhood overweight/obesity rises. Economic development has led to wide availability of highly processed foods and beverages, with growing evidence that children are consuming commercial snack products during the critical complementary feeding period. This study assessed the prevalence and patterns of consumption of commercially produced snack foods and sugar-sweetened beverages among Indonesian children. A cross-sectional survey was conducted with 495 mothers of children aged 6-35 months living in Bandung City, Indonesia. Among all children, 81.6% consumed a commercial snack food and 40.0% consumed a sugar-sweetened beverage in the day preceding the interview. At 6-11 months, 46.5% of children consumed a snack food and 2.0% consumed a sugar-sweetened beverage. Snack foods were consumed 3 or more times a day by 60.0% of children 24-35 months of age. Sweet biscuits and savory snacks were the most commonly consumed snack foods; sweetened milks and sweetened teas were the most common beverages. Maternal education, child age, and consumption of a commercially produced complementary food were associated with snack food consumption. Factors associated with sugar-sweetened beverage consumption were child age and consumption of a commercially produced complementary food or breastmilk substitute. These findings reflect a high presence of processed, high-sugar/salt commercial snack products in the diets of children 6-35 months. National attention should focus on interventions to reduce reliance on processed snack products and increase consumption of nutrient-rich, locally available foods during the complementary feeding period.

Energy intake from unhealthy snack food/beverage among 12-23-month-old children in urban Nepal.

Unhealthy snack food and beverage (USFB) consumption among young children has been noted in many low-income and middle-income countries (LMIC), however, there is a lack of information on the contribution of these foods to children's diets in these contexts. This study describes the nutrient profiles and costs of snacks consumed by young children in Kathmandu Valley, Nepal, and assesses the proportion of total energy intake from nonbreastmilk foods (%TEI-NBF) contributed by USFB and factors associated with high USFB consumption. A cross-sectional survey was conducted among 745 randomly sampled primary caregivers of children aged 12-23 months. Of 239 unique snack foods and beverages consumed, 180 (75.3%) were classified as unhealthy based on nutrient profiling, with 158 of these being commercially branded. Median cost/100 kcal of USFB was lower as compared with healthy snacks. Ninety-one percent of children had consumed a USFB in the previous 24 hr, with these foods contributing a mean %TEI-NBF of 24.5 ± 0.7 among all children. Biscuits (10.8%), candy/chocolate (3.5%), and savoury snacks (3.4%) provided the largest %TEI-NBF. Children who were older, female, or from the poorest households had significantly higher odds of high USFB consumption, whereas children whose caregivers were of upper caste/ethnicity or had achieved tertiary education had lower odds of consumption than other children. To reduce USFB consumption, interventions should seek to further understand social/cultural drivers of feeding practices, target disadvantaged populations, and ensure caregivers are fully aware of the nutritional quality of food products they choose for their children.

Perceptions of commercial snack food and beverages for infant and young child feeding: A mixed-methods study among caregivers in Kathmandu Valley, Nepal.

Ensuring nutritious complementary feeding is vital for child nutrition. Prior research in Kathmandu Valley found high consumption rates of commercially produced snack foods among young children, which are often energy-dense/nutrient poor. This mixed-methods study was conducted to elicit Nepali caregivers' perceptions of commercial snack foods and beverages and factors influencing their use for young child feeding. Seven facilitated focus group discussions (FGD) were conducted with Kathmandu Valley caregivers of children 12-23 months, and a survey of 745 primary caregivers of children 12-23 months of age was then conducted. During the FGD, caregivers reported commonly providing commercial food and beverage products to their children as snacks, and 98.6% of caregivers participating in the survey reported feeding their child such a food in the previous week. Because of processing and packaging, snack foods were not trusted by many FGD participants and considered as "junk foods" and not healthy for children. However, commercial snack foods were consistently ranked highly on convenience, both because of minimal preparation and ease of feeding; 48.5% of all surveyed caregivers reported providing a snack food because of convenience. Other family members' diets or provision of snack foods as treats also influenced children's consumption of these snack foods and beverages. This study indicates that caregivers of young children prefer snack options that are nutrient rich; however, this may conflict with preferences for foods that require minimal preparation and are appealing to young children. Such findings carry programmatic implications for interventions aiming to address children's diet quality in urban Nepal.

Predictors of breast milk substitute feeding among newborns in delivery facilities in urban Cambodia and Nepal.

Introducing breast milk substitutes (BMS) in the first days after birth can increase infant morbidity and reduce duration and exclusivity of breastfeeding. This study assessed determinants of BMS feeding among newborns in delivery facilities in Phnom Penh, Cambodia, and Kathmandu Valley, Nepal. Cross-sectional surveys were conducted among mothers upon discharge from health facilities after delivery: 304 mothers in Kathmandu Valley and 306 mothers in Phnom Penh participated. On the basis of a conceptual framework for prelacteal feeding, multivariable logistic regression was used to identify factors associated with BMS feeding prior to facility discharge. In both Phnom Penh and Kathmandu Valley, feeds of BMS were reported by over half of mothers (56.9% and 55.9%, respectively). Receiving a health professional's recommendation to use BMS increased the odds of BMS feeding in both Kathmandu Valley and Phnom Penh (odds ratio: 24.87; confidence interval [6.05, 102.29]; odds ratio: 2.42; CI [1.20, 4.91], respectively). In Kathmandu Valley, recommendations from friends/family and caesarean delivery were also associated with BMS use among mothers. Early initiation of breastfeeding and higher parity were protective against the use of BMS in Kathmandu Valley. Breastfeeding support from a health professional lowered the odds of BMS feeding among newborns. Exposure to BMS promotions outside the health system was prevalent in Phnom Penh (84.6%) and Kathmandu Valley (27.0%) but was not associated with BMS feeds among newborns. Establishment of successful breastfeeding should be prioritized before discharging mothers from delivery facilities, and health professionals should be equipped to support and encourage breastfeeding among all new mothers.

Prevalence, duration, and content of television advertisements for breast milk substitutes and commercially produced complementary foods in Phnom Penh, Cambodia and Dakar, Senegal.

Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.

Consumption of commercially produced snack foods and sugar-sweetened beverages during the complementary feeding period in four African and Asian urban contexts.

The availability and consumption of commercially produced foods and beverages have increased across low-income and middle-income countries. This cross-sectional survey assessed consumption of commercially produced foods and beverages among children 6-23 months of age, and mothers' exposure to promotions for these products. Health facility-based interviews were conducted among 218 randomly sampled mothers utilizing child health services in Dakar, Senegal; 229 in Dar es Salaam, Tanzania; 228 in Kathmandu Valley, Nepal; and 222 in Phnom Penh, Cambodia. In the day prior to the interview, 58.7% of 6-23-month-olds in Dakar, 23.1% in Dar es Salaam, 74.1% in Kathmandu Valley, and 55.0% in Phnom Penh had consumed a commercially produced snack food. In the previous week, the majority of children in Dakar (79.8%), Kathmandu Valley (91.2%), and Phnom Penh (80.6%) had consumed such products. Consumption of commercially produced sugar-sweetened beverages was noted among 32.0% of Phnom Penh, 29.8% of Dakar, 23.1% of Dar es Salaam, and 16.2% of Kathmandu Valley children. Maternal education was negatively associated with commercial snack food consumption in Dakar and Kathmandu Valley. Children of Phnom Penh mothers in the lowest wealth tercile were 1.5 times more likely to consume commercial snack food products, compared to wealthier mothers. These snack consumption patterns during the critical complementary feeding period demand attention; such products are often high in added sugars and salt, making them inappropriate for infants and young children.

Promotion and prelacteal feeding of breastmilk substitutes among mothers in Kathmandu Valley, Nepal.

UNLABELLED: In 1992, Nepal passed the Mother's Milk Substitutes (Control of Sale and Distribution) Act in order to regulate the sale, distribution and promotion of substitutes for breastmilk within Nepal, in an effort to protect and promote breastfeeding. Helen Keller International, in collaboration with Nepal's Ministry of Health and Population's Child Health Division, implemented a study to assess mothers' exposure to promotions for and utilization of breastmilk substitutes in Kathmandu Valley, Nepal. A health facility-based, cross-sectional survey was conducted among 304 mothers being discharged after delivery. Prelacteal feeding of breastmilk substitutes is prevalent (55.9% of mothers, n = 170). Reported recommendations during antenatal checks and after delivery from health professionals to use breastmilk substitutes were prevalent, occurring among 47.4% (n = 144) of mothers; rates of these recommendations were significantly higher for mothers that delivered in private health facilities, as compared with public (67.7% vs. 38.0%, P < 0.001). Mothers that received a recommendation to use a breastmilk substitute from a health worker were 16.7 times more likely to provide a prelacteal feed of a breastmilk substitute, as compared with mothers that did not receive a recommendation (P < 0.001). Few mothers reported observation of commercial advertisements for breastmilk substitutes inside a health facility (reported by 3.6% of mothers). No mothers reported receiving a sample of a breastmilk substitute, bottle or teat from a health professional. More information is needed to determine why there is such a high rate of health worker recommendations for breastmilk substitute use in the first few days after delivery. KEY MESSAGES: While utilization of breastmilk substitutes is low among mothers of young children in Nepal, prelacteal feeding of breastmilk substitutes is highly prevalent in Kathmandu Valley. Reported recommendations from health professionals to use breastmilk substitutes are common (over 40%) and are associated with prelacteal feeding among Nepal mothers included in this study. Provision of lactation management training to health workers and monitoring their practices regularly could strengthen breastfeeding counselling, aid in reducing high rates of prelacteal feeding and contribute to improved infant feeding practices.

Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding.

UNLABELLED: In 2005, Cambodia passed the Sub-Decree on Marketing of Products for Infant and Young Child Feeding (no. 133) to regulate promotion of commercial infant and young child food products, including breastmilk substitutes. Helen Keller International assessed mothers' exposure to commercial promotions for breastmilk substitutes and use of these products through a cross-sectional survey among 294 mothers of children less than 24 months of age. Eighty-six per cent of mothers reported observing commercial promotions for breastmilk substitutes, 19.0% reported observing infant and young child food product brands/logos on health facility equipment and 18.4% reported receiving a recommendation from a health professional to use a breastmilk substitute. Consumption of breastmilk substitutes was high, occurring among 43.1% of children 0-5 months and 29.3% of children 6-23 months of age. Findings also indicated a need to improve breastfeeding practices among Phnom Penh mothers. Only 36.1% of infants 0-5 months of age were exclusively breastfed, and 12.5% of children 20-23 months of age were still breastfed. Children that received a breastmilk substitute as a prelacteal feed were 3.9 times more likely to be currently consuming a breastmilk substitute than those who did not. Despite restriction of commercial promotions for breastmilk substitutes without government approval, occurrence of promotions is high and use is common among Phnom Penh mothers. In a country with high rates of child malnutrition and pervasive promotions in spite of restrictive national law, full implementation of Cambodia's Sub-Decree 133 is necessary, as are policies and interventions to support exclusive and continued breastfeeding. KEY MESSAGES: Despite prohibition without specific approval by the national government, companies are pervasively promoting breast-milk substitutes in Phnom Penh, particularly on television and at points of sale. Strengthened implementation and enforcement of Cambodia's subdecree 133 are needed to better regulate promotion in order to protect breastfeeding for the nutrition and health of infants and young children in Cambodia. Mothers who used a breast-milk substitute as a prelacteal feed were 3.9 times more likely to currently feed this same child a breast-milk substitute, as compared with mothers who did not provide breast-milk substitute as a prelacteal feed. Supporting breastfeeding among mothers after delivery is critical to establish and sustain optimal breastfeeding practices. Use of breast-milk substitutes is also very common among mothers of children under 2 years of age in Phnom Penh. We recommend promoting exclusive and continued breastfeeding as beneficial to children's health and development, and supporting policy and workplace environments that enable breastfeeding up to and beyond 24 months of age.

High use of commercial food products among infants and young children and promotions for these products in Cambodia.

Despite national improvements in child survival, 40% of Cambodian children less than 5 years of age are stunted. Commercially produced complementary foods could be nutritionally beneficial for young children in Cambodia if fortified and of optimal nutrient composition. However, other nutrient-poor commercially produced snack foods may be detrimental to young child feeding by displacing consumption of other nutritious foods. This study assessed consumption of commercial food products among infants and young children and their mothers' exposure to promotions for these products. A cross-sectional survey was conducted among 294 mothers of children less than 24 months of age living in Phnom Penh. Of children 6-23 months of age, 55.0% consumed a commercially produced snack food product on the prior day, and 80.6% had consumed one in the prior week. Only 12 (5.4%) children 6-23 months of age had consumed a commercially produced complementary food. Almost all mothers (96.9%) had observed a promotion for a commercially produced snack food product, and 29.3% reported observation of a promotion for a commercial complementary food. Only one-third (32.9%) of children 6-23 months of age achieved a minimum acceptable diet. Findings indicate that there is a need to improve infant and young child feeding practices among children less than 24 months of age living in Phnom Penh. Nutritious options should be promoted, and consumption of unhealthy commercially produced snack food products should be discouraged.

High consumption of commercial food products among children less than 24 months of age and product promotion in Kathmandu Valley, Nepal.

Commercially produced complementary foods can help improve nutritional status of young children if they are appropriately fortified and of optimal nutrient composition. However, other commercially produced snack food products may be nutritionally detrimental, potentially increasing consumption of foods high in salt or sugar and displacing consumption of other more nutritious options. Helen Keller International, in collaboration with the Nepal government, implemented a study to assess mothers' utilization of commercial food products for child feeding and exposure to commercial promotions for these products. A cross-sectional survey was conducted among 309 mothers of children less than 24 months of age across 15 health facilities. Utilization of breastmilk substitutes was low, having been consumed by 6.2% of children 0-5 months of age and 7.5% of children 6-23 months of age. Approximately one-fourth (24.6%) of children 6-23 months age had consumed a commercially produced complementary food in the prior day. Twenty-eight percent of mothers reported observing a promotion for breastmilk substitutes, and 20.1% reported promotions for commercially produced complementary foods. Consumption of commercially produced snack food products was high at 74.1% of children 6-23 months. Promotions for these same commercially produced snack food products were highly prevalent in Kathmandu Valley, reported by 85.4% of mothers. In order to improve diets during the complementary feeding period, development of national standards for complementary food products is recommended. Nutritious snack options should be promoted for the complementary feeding period; consumption of commercially produced snack food products high in sugar and salt and low in nutrients should be discouraged.