|Year : 2019 | Volume
| Issue : 2 | Page : 217-223
“When,” “What,” and “How” of complementary feeding: A mixed methods cross-sectional study from a rural medical college in central India
Priyanka A Joshi, Shiv H Joshi, Abhishek V Raut
Department of Community Medicine, MGIMS, Wardha, Maharashtra, India
|Date of Submission||26-May-2019|
|Date of Decision||28-Nov-2019|
|Date of Acceptance||06-Dec-2019|
|Date of Web Publication||16-Dec-2019|
Dr. Abhishek V Raut
Department of Community Medicine, MGIMS, Sewagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aim: Undernutrition among under-five children is one of the most important public health problems in India. Despite several years of efforts to tackle undernutrition, India has not been able to make any significant dent on proportion of undernutrition. The aim of this study is to assess the quality of complementary feeding (CF) practices among mothers visiting immunization clinic of a rural medical college in central India. Materials and Methods: This hospital-based study was conducted among 190 consecutively recruited children between 6 and 23 months of age who visited the immunization clinic. Study design involves cross-sectional study using mixed methods. Sociodemographic details were recorded and anthropometric measurements were done using calibrated infantometer and electronic weighing scale. The adapted CF index (CFI) was administered that included questions on continuation of breast-feeding, initiation of CF, dietary diversity, food frequency, and responsive feeding. Freelisting was conducted with 20 different mothers. Calorific value of CF given was determined based on 24-h dietary recall. Results: The magnitude of underweight, stunting, and wasting was 25.8%, 27.9%, and 10%, respectively. Almost all (91.6%) of the children had received timely initiation of CF, but only 67.4% children had received dietary diversity and 75.5% of nonbreast fed and 77.7% of breast fed children received appropriate meal frequency. The CFI and calorific value of food had significant positive correlation. CFI score was significantly associated with stunting (Prevalence odds ratio (POR) 8.37, 95% Confidence interval: 1.09–64.2). The findings of CFI triangulate with findings of freelisting. The study participants showed poor intake of flesh foods (meat and eggs) and Vitamin-A rich fruits and vegetables. Starchy staples and other fruits were consumed more readily. Conclusion: CFI helps to readily assess the quality of CF. Complementary feeds given were not adequate in terms of minimum dietary diversity, meal frequency, and provision of required calories and protein.
Keywords: Complementary feeding, infant and young child feeding, malnutrition, responsive feeding
|How to cite this article:|
Joshi PA, Joshi SH, Raut AV. “When,” “What,” and “How” of complementary feeding: A mixed methods cross-sectional study from a rural medical college in central India. Arch Med Health Sci 2019;7:217-23
|How to cite this URL:|
Joshi PA, Joshi SH, Raut AV. “When,” “What,” and “How” of complementary feeding: A mixed methods cross-sectional study from a rural medical college in central India. Arch Med Health Sci [serial online] 2019 [cited 2022 Jun 27];7:217-23. Available from: https://www.amhsjournal.org/text.asp?2019/7/2/217/273076
| Introduction|| |
Nutrition plays a key role in growth and development of children. Lack of adequate nutrition in the initial years has profound, long-lasting, irreversible consequences across the life cycle. The deleterious effects include but may not be limited to stunting, impaired brain development, poorer health status, poor academic performance, and compromised economic productivity. Nearly 45% of all under-five deaths are attributed to undernutrition.,,
India has one of the highest burdens of child undernutrition in world contributing to more than half (54%) of all under-five deaths. Although some reduction is seen in rates of stunting, wasting, and underweight, India has not been able to make a significant dent on child undernutrition despite having numerous programs for the same.,,,,
Undernutrition usually sets in between the age group of 6 and 12 months, especially after the introduction of complementary feeds and is thus associated with the inadequate complementary feeding (CF) practices. Once undernutrition sets in, it is extremely difficult and resource intensive to treat and compensate the deficits beyond 2 years of age.,
Burden of undernutrition is significant even in the district where this research work was conducted. The National Family Health Survey-4 (NFHS-4) factsheet for the rural area of district shows 29.7% stunting, 33.5% underweight, and 29.7% wasting in under-five children.
Currently, health messages focus more on breast feeding, frequency, and timely start of CF only. However, the quality of CF is a domain not focussed on. With this background, the present study was conducted with a primary objective to assess the quality of CF using the adapted CF index (CFI). The secondary objectives included to estimate accuracy of CFI for providing the needed Calorific value to a child and to study the association of CF with nutritional status of children.
| Materials and Methods|| |
This hospital-based cross-sectional study was conducted using mixed methods between July and September 2018 among children between 6 and 23 months of age who visited the immunization clinic of the hospital. This age group was selected as undernutrition in a child sets in during this age group.
The study was initiated after prior approval from the Institutional Ethics Committee for Human subjects. Only children whose mothers gave written informed consent for her child's participation were included in the study.
Estimated sample size using the OpenEpi software (Emory University Atlanta, GA, USA) was 190 assuming a 95% of confidence level, prevalence of underweight in the study setting (P) = 33.5%, an absolute precision of 10%, a design effect of 2, and a 10% loss of data or incomplete data. We used consecutive sampling and offered participation to each successive child who visited the immunization clinic till the desired sample size of 190 was recruited. Children who came for immunization with other relatives, had any acute illness in preceding 2 weeks, had congenital defects, and low birth weight were excluded from the study.
Data were collected by individually interviewing the mother's maintaining confidentiality and privacy. A pretested structured interview schedule was used to collect sociodemographic information such as mother's age, education, occupation, economic status, type of family, and birth order and gender of child. A CFI was adapted from a previously done study in India., A score of “0” for a negative practice, “2” for a positive practice, and “1” for a practice that was in between was given as per the World Health Organization-Infant Young Child Feeding (WHO-IYCF) guidelines., CFI included a section on responsive feeding with 9 questions, each marked based on the care givers responsiveness from 0 to 2 as stated above. For questions on responsive feeding a tool used in Bangladesh by Aboud et al. was adapted and used. Theoretically, the CFI score ranged from 0 to 25 and was grouped into terciles to form three categories: Poor, average, and good quality CF practices.
Freelisting was conducted with mothers till saturation to identify the commonly given and avoided complementary food items, to the child with reasons thereof since CF started. The calorific value of food was assessed, by asking mothers the approximate amount of cooked food given to the child on the previous day using the calibrated measuring cups and accordingly reference values for cooked food preparations based on nutritive value of Indian foods were used. Anthropometry was done using standard calibrated electronic weighing scale and infantometer. Mothers who were found to be indulging in faulty feeding practices were counseled as per the IYCF guidelines., Mothers of children found to have undernutrition were counseled regarding proper feeding practices and responsive feeding.
- Timely initiation of CF: Infants receiving CF in addition to breast milk from 6 months of age onward
- Minimum dietary diversity: Proportion of children 6–23 months of age who received foods from four or more food groups out of following-grains, roots and tubers, legumes and nuts, dairy products (milk, yoghurt, and cheese), flesh foods (meat, fish, poultry, liver/organ meats), eggs, Vitamin A rich fruits and vegetables, and other fruits and vegetables
- Minimum meal frequency: Proportion of breastfed and nonbreastfed children 6–23 months of age who received solid, semi-solid, or soft foods the minimum number of times or more: 2 for 6–8 months if breastfed, 3 for 9–23 months if breastfed, and 4 for 6–23 months if not breast fed
- Standard definitions of underweight, stunting, and wasting were considered as defined in the WHO Child Growth Standards.
| Results|| |
[Table 1] depicts the sociodemographic details of the study participants. Among the study participants, there were 102 (53.6%) males and 88 (46.4%) females. One hundred and thirty-five (71%) children were the first born to their parents. One hundred and fifty-six (82.2%) of the children were from joint families. About 31 (16.4%) participants reported having no ration card, out of the remaining 159 participants, 146 (76.8%) were above poverty line, whereas 13 (6.8%) were below poverty line. 181 (95.3%) mothers interviewed were home-makers. All the mothers were literate, with 136 (71.6%) having received higher education. All the mothers had age 20 years and above, and 165 (86.8%) of them were below the age of 30 years.
[Table 2] depicts the CF practices among the study participants. One hundred and fifty-seven (82.6%) were on continued breastfeeding. 174 (91.6%) were initiated on CF at around 6 months of age that is timely. It can be seen that all mothers provided their children with diverse foods in the past 24 h, but only 67.4% fulfilled the criteria of minimum dietary diversity. A major proportion of CF was of starch staples (grains, roots, tubers) and was provided to more than three-fourth (76.3%) children. The overall feeding of pulses, legumes, and nuts was found to be average with 65.2% and even 25.7% with no intake at all. Milk products were also found to be least consumed, with more than half children (65.2%) never receiving it and very less proportion (18.5%) of children receiving it >4 times in the past week. Consumption of flesh foods (meat and eggs) was average in only 29.4% of children, with more than half (64.7%) not receiving it in the past 7 days. Only a minor proportion (7.4%) received Vitamin-A rich fruits and vegetables in good proportion, while 71.6% who received it averagely 1–3 times in the past week. Consumption of other fruits and vegetables was relatively better, with 17.5% receiving it >4 times and 68.9% receiving it 1–3 times in the past 7 days. About half (52.6%) children consumed food made with oil, fat, and butter 1–3 times, while only 16.3% who never consumed it. The criteria for minimum meal frequency are different for breast fed and nonbreastfed children. Out of the 33 nonbreastfed children under study, more than three-fourths (84.8%) satisfied this criteria. Among the 157 breast fed children again a majority (77.7%) received meals >4 times in the past 24 h and only 22.3% receiving it 1–3 times that is averagely. No mothers received poor scores for responsive feeding questionnaire that is 0–6. About 63.2% of participants received average score of 7–14, whereas 36.8% got a good score in the range 15–18.
[Table 3] represents the CFI score calculated by summing the individual scores in CFI table for each participant. The sample of 190, thus, falls in three categories with only 1 participant with a low score of (≤8). A majority of 88.6% of participants were in the age group of 9–17 years with medium score in. About 10% have a high score with 18–25.
[Table 4] gives the calorie and protein intake in the past 24 h as assessed by the 24-h dietary recall. Mean calorie intake of all children was 740.9 kcal, with median caloric intake being 726 kcal. The minimum calorie intake was of 265 kcal and maximum for a child was 1175 kcal. Mean protein consumed in grams was 23.8 with standard deviation (SD) 5.4. The minimum protein intake was of 6.6 g and maximum of 36.4 g. A significant positive correlation was seen between CFI and calorie and protein value of food with correlation coefficient being 0.67 and 0.59, respectively, at P < 0.05.
|Table 4: Calorific value of food intake in the past 24 h and its correlation with complementary feeding index|
Click here to view
[Table 5] shows association between the CFI scores and nutritional status. The proportion of children who were underweight, stunted, and wasted was 49 (25.8%), 53 (27.9%), and 19 (10%), respectively. Children with low-medium CFI score had higher Odds for being underweight than children with high CFI score. However, this association was not statistically significant (POR 2.10 95% confidence interval [CI] 0.59–7.51). Similarly, children with low-medium CFI score had higher odds for wasting than children with high CFI score. However, this association of wasting with CFI score was not statistically significant (POR 2.25 95% CI 0.28–17.82). The association of CFI score with stunting in children was found to be statistically significant (POR 8.37 95% CI 1.09–64.2).
|Table 5: Association between the complementary feeding index scores and nutritional status|
Click here to view
Freelisting was conducted with 20 mothers separately for determining the CF given and avoided to a child. [Table 6] represents such salient food items given and avoided with their frequency, average rank and Smith's Salience values. These results triangulate with the findings of CFI and nutritional status of the children under study. The findings show that children are given more items that fall within the food group 1 of starchy staples (grains, roots, and tubers) with Dal-Rice being the most frequent cereal. Pulses are included in the form of Daal or mixed as part of Khichdi. However, consumption of Vitamin A rich fruits and green leafy vegetables is poor. Mothers reported giving the food items given as per the traditional practice in their house. Respondent M-13 quoted – “Gharat jasa chalat aala ahe tasach amhi pan karto and porana khau ghalto, aai/sasubai saangtat.” (Whatever feeding practices have been continuing in our household we follow those as advised by the mother/mother-in-law). Furthermore, some of the mothers informed that they also follow the advice given by the health-care staff after delivery. Respondent M-2 said, “Delivery chya veli dawakhanyat jasa sangitla tasa pan karto, varnacha paani, varan-bhaat, varan-poli gharatlach anna deto”. (We also follow what was told to us at the time of delivery in hospitals such as giving homecooked food in form of daal water, daal rice, daal roti).
Mothers reported avoiding food items that were oily and spicy. Respondent M-16 informed that, “Amhi poran sathi vegla anna shijavto, mothya mansancha tikhat-telkat jevan balala det nahi”. (We cook separately for children and do not give spicy-oily food that is cooked for adults to them). Mothers reported avoiding other food items such as eggs, nonvegetarian food, curd, bananas by virtue of their properties like being hot or cold in nature or easy or heavy for digestion. Respondent M-7 said that, “Anda/Non-veg pachayla jadd asta mhanun det nahi.” (We don't give egg/non-veg as it is heavy for digestion) while respondent M-14 mentioned that, “Dahi, keli thanda astat ani tyamule mulana cough hoto”. (Curd, banana are “cold” in nature that lead to cough). Another important observation was avoidance of leafy vegetables and flesh foods. These food items are of very high nutritive value and are still not given to the children. Respondent M-4 said that, “Palak bhaji mulanna kadu lagte ani awdat nahi mhanun nahi det.” (Children find Spinach bitter to taste and don't like it hence we don't give it to children).
| Discussion|| |
The objective of the study was to assess the quality of CF and to associate the results with nutritional status of children. Study was conducted in routine immunization OPD of a tertiary care hospital with a sample size of 190.
The literacy rates of rural Maharashtra in the year 2015–2016 as per the NFHS-4 were 80.3% and especially for females was 74.8%. In this study, literacy rate was 100% among study participants probably because the study was conducted in an immunization OPD of a tertiary care hospital where only the most health literate would approach. Children of age 6–8 months who receive solid or semi-solid food and breast milk indicates timely initiation of CF. In rural Maharashtra, this rate was 38.8% as per NFHS-4 (2015–2016). In our study, this rate was found to be 91.6%. The reason for the higher rates must be because study was hospital based and the study participants had high literacy rates which also indicate high sense of awareness regarding child's well-being.
Burden of undernutrition is significant even in the district where this research work was conducted. NFHS-4 factsheet for the rural area of district shows 29.7% stunting, 33.5% underweight, and 29.7% wasting. In this study, the prevalence of underweight, stunting, and wasting was 25.8%, 27.9%, and 10%, respectively. This difference could be because the values for undernutrition as per NFHS-4 are for children under 5 years of age. Furthermore, it was conducted in a much greater population consisting of much larger population. Whereas the study was restricted to only 190 children in the 6–23 months age group who visited the hospital for immunization. Rahman et al. conducted a study in children under 5 years in Bangladesh and the results revealed very high undernutrition, 51% stunting, 25% wasting, and 52% underweight. These higher rates are because this study was conducted in low-birth-weight children, also these results are for under-5 years of age children. In our study, we specifically excluded the low-birth-weight children in order to remove the confounding effect of low birth weight.
Olatona et al., in 2017, conducted a descriptive cross-sectional study in Nigeria; data were collected from mothers and infants and showed dietary diversity of 16% only. In our study, the dietary diversity is found to be 67.4%. This is because of the different study setting, sample size, and various health and nutrition schemes being implemented in the country as compared to Nigeria. Sie et al. conducted a study among children in rural Burkina Faso. Out of the 251 children enrolled in the study, 20.6% were stunted, 10.0% wasted, and 13.9% underweight. Greater dietary diversity was associated with greater height for age Z score (SD: 0.14, 95% CI 0.04–0.25) among all children. Our study showed almost similar results in terms of significant association of high CFI scores with stunting. However, there is a vast difference in the two studies as the sample population was 6–59 months old children compared to ours which is younger age group (6–23 months) also there is a variation in trends of dietary diversity based on differences in crop yields in the two study settings. The association of CFI and height for age is significant and those with low-to-medium CFI have significantly higher odds of stunting. Stunting is a marker of chronic undernutrition. Furthermore, a strong correlation of CFI and calorific value indicates that, in general, among the study group most children are not receiving CF of high nutritive value and in turn having low calorie and protein intake which has a significant impact on their nutritional status.
The recommended allowance for the Indian children suggests 80 kcal/kg (for 6 months–1-year child) and 1060 kcal for child 1–2 years of age, while the recommended value of proteins is of 1.25 g/kg. The dietary diversity pattern as seen from above shows less nutritive value (calorie and protein) derived from food represented by mean calorie intake 740.9 kcal and mean protein intake 23.8 g both being less than the recommended daily allowances. As CFI correlates significantly with the caloric intake values, CFI can be used as a proxy to assess the nutritive value of food given to children. CFI is easy tool compared to calculation of calorie and protein intake and so can be used in monitoring the quality of CF.
Free listing analysis revealed that the children were predominantly given starchy staple grains and pulses. Foods with high nutritive value like fruits, flesh foods (eggs, meat etc.), and Vitamin-A rich fruits and green leafy vegetables were avoided or minimally given. This data are consistent with the food frequency data of CFI. About 76.3% of children were given adequate amount of starchy staples, whereas only 5.9% received flesh foods and 7.4% received Vitamin A rich fruits and vegetables in adequate amount. The same is reflected from the calorific data table the nutritional status of the children under study. The reasons for food items given/avoided reveal that even in a 100% literate population, many faulty perceptions regarding CF exist. The quality of counseling regarding IYCF practices in the hospitals needs to be improved with emphasis given on food diversity and responsive feeding and not just restrict to food frequency or quantity. The advice given in hospitals does influence the complementary foods given as depicted from the reasons for food items given in the free-listing exercise.
The study had optimum sample size and was adequately powered to meet its objectives. Measurement bias was minimalized by utilizing calibrated infantometer and electronic weighing scale for measuring height and weight, respectively, which were available in the hospital. Validation of findings was done by data triangulation using mixed method. The study may not be representative of the general population as only those who visited the immunization clinic were included in the study. As the questionnaire included questions that would relate to responsiveness and ability to feed child, a possibility of over-reporting may not be denied despite our best efforts.
| Conclusion|| |
The quality of complementary feeds given was not adequate in terms of minimum dietary diversity, meal frequency and provision of required calories and protein. CFI correlates significantly with the caloric intake values and can be used in monitoring the quality of CF. The quality of counselling regarding IYCF practices in the hospitals needs to be improved with emphasis given on food diversity and responsive feeding and not just restrict to food frequency or quantity.
- We acknowledge the mothers of all the infants who spared their valuable time for answering the questions related to the present study
- We also acknowledge the support from Faculty and Staff of Department of Community Medicine, MGIMS, Sevagram, toward completion of this research work.
Financial support and sponsorship
This study was financially supported by Short-term Studentship program of the Indian Council of Medical Research (ICMR-STS).
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Nurturing Care for Early Childhood Development: A Framework for Helping Children Survive and Thrive to Transform Health and Human Potential. World Health Organization; 2018.
Caulfield LE, de Onis M, Blössner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr 2004;80:193-8.
International Institute for Population Sciences. National Family Health Survey (NFHS-1:MCH and Family planning), India 1992-93. Mumbai: International Institute for Population Sciences; 1995.
International Institute for Population Sciences (IIPS) and ORC Macro. National Family Health Survey (NFHS-2), 1998-99: India. Mumbai: International Institute for Population Sciences; 2000.
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India. Vol. 1. Mumbai: International Institute for Population Science; 2007.
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: International Institute for Population Sciences; 2017.
Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. Worldwide timing of growth faltering: Revisiting implications for interventions. Pediatrics 2010;125:e473-80.
World Health Organization. WHO Programme of Nutrition Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva: World Health Organization; 1998. Available from: https://apps.who.int/iris/handle/10665/65932
. [Last accessed on 2019 Jun 26].
Rahman MS, Howlader T, Masud MS, Rahman ML. Association of low-birth weight with malnutrition in children under five years in Bangladesh: Do mother's education, socio-economic status, and birth interval matter? PLoS One 2016;11:e0157814.
Garg A, Chadha R. Index for measuring the quality of complementary feeding practices in rural India. J Health Popul Nutr 2009;27:763-71.
Lohia N, Udipi SA. Infant and child feeding index reflects feeding practices, nutritional status of urban slum children. BMC Pediatr 2014;14:290.
Aboud FE, Shafique S, Akhter S. A responsive feeding intervention increases children's self-feeding and maternal responsiveness but not weight gain. J Nutr 2009;139:1738-43.
Abeshu MA, Adish A, Haki GD, Lelisa A, Geleta B. 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. Front Nutr 2016;3:32.
World Health Organization. WHO Child Growth Standards. Length-for-Age, Weight-for-Age, Weight-for-Length. Methods and Development. Department of Nutrition for Health and Development. Geneva: World Health Organization; 2006.
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), India, 2015-16: Maharashtra. Mumbai: International Institute for Population Sciences; 2018.
Olatona FA, Adenihun JO, Aderibigbe SA, Adeniyi OF. Complementary feeding knowledge, practices, and dietary diversity among mothers of under-five children in an urban community in Lagos state, Nigeria. Int J MCH AIDS 2017;6:46-59.
Sié A, Tapsoba C, Dah C, Ouermi L, Zabre P, Bärnighausen T, et al.
Dietary diversity and nutritional status among children in rural Burkina Faso. Int Health 2018;10:157-62.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]