ICAN: Infant, Child, & Adolescent Nutrition

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Feeding Practices and Nutrition Outcomes in Children : Examining the Practices of Caregivers Living in a Rural Setting Joyce Nankumbi, Joshua Kanaabi Muliira and Margaret K. Kabahenda ICAN: Infant, Child, & Adolescent Nutrition 2012 4: 373 originally published online 12 July 2012 DOI: 10.1177/1941406412454166 The online version of this article can be found at: http://can.sagepub.com/content/4/6/373

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Evidence-Based Practice Reports

Feeding Practices and Nutrition Outcomes in Children Examining the Practices of Caregivers Living in a Rural Setting Joyce Nankumbi, RN, BSN, Joshua Kanaabi Muliira, RN, BSN, MA, MSN, DNP, and Margaret K. Kabahenda, BSc, MSc, PhD Abstract: Malnutrition has lifelong and irreversible effects, especially when it occurs in the early stages of infancy. This study examined infants and young children feeding practices (IYCFPs) using the Child Feeding Index (CFI) in a sample of 232 children aged 0 to 24 months and their caregivers living in a rural Ugandan district. A cross-sectional design was used to collect data about the children’s weight and height and the feeding practices of their caregivers. Results show that caregivers’ IYCFPs were suboptimal. The majority of caregivers were biological mothers of the children (97%), but their practice of exclusive breastfeeding was low (34%). Most mothers initiated breastfeeding early (61%) but also introduced other feeds before the recommended time. Complementary feeding was characterized by early introduction of age-inappropriate feeds and inadequate feeding. The CFI showed that only 39% of children in the age group of 9 to 12 months and 9% of children in the age group of 12 to 24 months received the recommended number of meals in a day. Analysis of children’s nutritional status showed that 33% were stunted and 13% were underweight, and there were significant differences

in nutrition outcome of the children according to their caregivers’ IYCFPs. Keywords: nutrition; feeding practices; child feeding index; rural; Uganda

Introduction Undernutrition is responsible for approximately 35% of deaths in children younger than 5 years worldwide1 and

causes of malnutrition in children are many and diverse, but it has been recognized that poor feeding practices by caregivers are a major contributing factor.4 The feeding practices used by the child’s caregiver during the period from birth to 2 years of age are important because at this critical stage, essential physical and cognitive growth and development takes place.5 Realization of the importance of feeding practices to the nutrition and health outcomes of children 0 to 2 years of age has

“The causes of malnutrition in children are many and diverse, but it has been recognized that poor feeding practices by caregivers are a major contributing factor.” is one of the common factors that prevent children who survive from reaching their full developmental potential.2 Government estimates show that malnutrition affects 40% of Ugandan children younger than 5 years of age and has led to stunting or underweight especially among those living in rural areas.3 The

led to a worldwide focus on strategies to promote appropriate feeding practices.6 Currently, the World Health Organization and other international health agencies recommend that breastfeeding should be initiated within the first hour after delivery and that a mother should continue to exclusively breastfeed the child for the first

DOI: 10.1177/1941406412454166. From the Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda (JN); College of Nursing, Sultan Qaboos University, Muscat, Oman (JKM); and School of Food Technology and Bioengineering, College of Agricultural Sciences, Makerere University, Kampala, Uganda (MK). Address correspondence to Margaret K. Kabahenda, Department of Food Technology and Nutrition, College of Agricultural and Environmental Sciences, Makerere University, P.O. Box 7062, Kampala, Uganda; e-mail: [email protected] or [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2012 The Author(s)

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6 months after birth. After 6 months, it is recommended that the child should be fed on complementary feeds in addition to breastfeeding, and this practice should continue until the age of 24 months.1 These recommendations have been adopted by government health authorities in many developing countries. However, national survey reports from countries such as Uganda continue to show that a large number of mothers do not initiate breastfeeding within the first hour of delivery and give their babies prelacteal feeds.3 In Uganda, national statistics show that a large number of mothers with children 0 to 6 months old do not exclusively breastfeed (40%), 20% of children of age 6 to 9 months do not get timely complementary feeding, and 72% of children aged 6 to 23 months receive inadequate complementary feeds.3 Similar trends of poor child feeding practices have been reported in Ethiopia7 and in Limpopo province of South Africa.8 The International Baby Food Action Network report on infant and young child feeding practices in 33 countries located in Africa, Asia, Latin America, and the Caribbean also shows closely similar rates of noncompliance with infant and young child feeding recommendations.6 One of the explanations for the low rates of compliance with the internationally recognized and recommended infants and young children feeding practices (IYCFPs) is lack of support for women in the health care facilities and communities where they live to help them carry out optimal child feeding practices.6 The other factors include maternal death during or immediately after childbirth and the subsequent outcomes, such as children being taken care of by extended family members such as grandmothers who are not in a position to breastfeed the child and are more likely to use more traditional feeding practices. Although the problem of lack of compliance with recommended IYCFPs has been reported about in developing countries, this has been mostly based on data collected from large hospitals in urban areas of these countries. The phenomenon has been understudied among children and children’s caregivers living in rural areas of developing countries. This knowledge gap needs to be bridged

because studies of IYCFPs increase our understanding of critical behaviors related to outcomes of children’s nutrition, general well-being, and health.9 The critical behaviors and practices of child caregivers related to breastfeeding, dietary diversity, food frequency, and meal frequency affect health and developmental outcomes in young children. Therefore, the purpose of this study was to examine IYCFPs and associated nutrition outcomes in children aged 0 to 24 months living in a rural Ugandan district. Methods and Procedures A cross-sectional design was used to collect data from participants found in 232 households. The study was approved by the Uganda National Council of Science and Technology and was conducted in Luweero, a rural district located in Central Uganda. The sample for this study was acquired by obtaining a list of administrative divisions of the district from the District Authorities. The list was used to randomly select the counties and subcounties from which participants for the study were recruited. Two subcounties were randomly selected from each of the initially selected counties. In each subcounty, 2 parishes and subsequently villages were selected as the locales from which participants were recruited. In each village, a list of households was used to determine the sampling interval and households to be approached to participate in the study. Prior to approaching the household from where participants were enrolled, village leaders were requested to provide a list of households with children aged 0 to 24 months. The list, maintained by village leaders as part of the local government administration public records, was matched with the randomly selected households. In cases where the household that was randomly selected had no participants meeting the inclusion criteria, the next household was considered. From the list provided, households with children of appropriate age (0-24 months) were identified and notified about the study. Households with children born with congenital abnormalities were excluded from the study. In each selected

household, 1 child who met the inclusion criteria was included in the study. The inclusion criteria for this study were as follows: household with at least 1 child of age 0 to 24 months, biological mother or regular caregiver is available and consents to participate in the study, and caregiver consents to allow child’s measurements to be taken. On entry into each household, the mother or caregiver was provided an explanation about the purpose and procedures related to the study and signed the informed consent form before the child was screened for eligibility using the birth date listed on the child’s health card or a date provided verbally by the caregiver. A total of 232 caregiver-child pairs formed the sample for this study. Data Collection

Caregivers were interviewed using a questionnaire comprising a section on sociodemographic characteristics and Child Feeding Index (CFI). Data on intake of complementary foods was collected using a 24-hour recall and a 7 days’ food frequency questionnaire. In all households, the questionnaire on characteristics and practices was administered first, followed by the food frequency questionnaire and 24-hour recall questionnaire. After these procedures, the family felt comfortable enough for the child’s measurements to be taken. The child’s measurements taken were weight and length. The weight of children was measured using a UNICEF digital weighing scale (manufactured by SECA Company) and length using a UNICEF model height/length board (0.1 cm sensitivity). Scoring of the CFI

The CFI is a composite index used for global assessment of IYCFPs and was developed in 2002 for use in developing countries.9-11 The domains of the CFI are based on the current infant and young child feeding recommendations.12 A score is generated for each of the 4 CFI domains (breastfeeding, dietary diversity, food frequency, and meal frequency). The CFI defines optimal feeding practices for 3 different age groups as follows: 6 to 9 months (breastfeeding plus gradual introduction of complementary foods); 9 to

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Table 1. Scoring of the Child Feeding Index for IYCFPs Variable

6-9 Months

9-12 Months

12-24 Months

Breastfeeding

No = 0; Yes = +2

No = 0; Yes = +2

No = 0; Yes = +2

Dietary diversity

Sum of (grains + tubers + milk + egg/fish/poultry + meat + other): 0 = 0; 1-3 = 1; 4+ = 2

Sum of (grains + tubers + milk + egg/fish/poultry + meat + other): 0 = 0; 1-3 = 1; 4+ = 2

Sum of (grains + tubers + milk + egg/ fish/poultry + meat + other): 0 = 0; 1-3 = 1; 4+ = 2

Food frequency (past 7 days)

For each of egg/fish/poultry and meat: 0 times in past 7 d = 0; 1-3 times in past 7 d = 1; 4+ times in past 7 d = 2. For staples (grains or tubers): 0-2 times = 0; 3+ times = 1. Food group frequency = sum of scores for staples + egg/fish/ poultry +meat

For each of egg/fish/poultry and meat: 0 times in past 7 d = 0; 1-3 times in past 7 d = 1; 4+ times in past 7 d = 2. For staples (grains or tubers): 0-2 times = 0; 3+ times = 1. Food group frequency = sum of scores for staples + egg/fish/ poultry + meat

For each of egg/fish/poultry + meat: 0 times in past 7 d = 0; 1-3 times in past 7 d = 1; 4+ times in past 7 d = 2. For staples (grains or tubers): 0-2 times = 0; 3+ times = 1. Food group frequency = sum of scores for staples + egg/fish/poultry + meat

Meal frequency (past 24 hours)

0 meals/d = 0; 1 meal/d= 1; 2 meals/d = 2

0 meals/d = 0; 1 meal/d= 1; 2 meals/d = 2

0 meals/d = 0; 1 meal/d= 1; 2 meals/d = 2

Total score

0/+11 points

0/+11 points

0/+11 points

Abbreviation: IYCFP, infants and young children feeding practice. Source: Adapted from Arimond and Ruel, 200213

12 months (similar to that for 6-9 months but increasing the amount and frequency of complementary feeding); and 12 to 24 months (continued breastfeeding for as long as possible, gradual transition to the family diet, and focus on dietary quality). As shown in Table 1, each item of the CFI is scored by assigning a value of 0 for a potentially harmful practice and a score of 2 for a positive practice. The practices that are between potentially harmful and positive are scored as 1. The scores on each item were added to obtain scores for each domain. Within each age group, the CFI scores were grouped into terciles to form 3 categories of child feeding practices: low, average, and high. Results Characteristics of Caregivers and Their Children

Results summarized in Table 2 show that the majority of caregivers were biological mothers (97%), married (84%), employed as farmers (69%), and had

attained only a primary school level of education (62%). A large number of caregivers were in the age range of 20 to 29 years (53%; mean = 27.43 ± 8.21). The youngest caregivers were 15 years of age, and the average number of children per household was 1.2. The majority of children were in the age range of 12 to 24 months (50%). Addition analysis showed that 40% of the children had some type of malnutrition (wasting, stunting, or underweight), and there was a significant positive correlation between the caregiver’s age and CFI score (r2 = 0.49; P = .004). Increasing age of the caregiver was associated with better IYCFPs. Breastfeeding Practices and Types of Prelacteal Feeds Used by Caregivers

At the time of the interview, all caregivers reported that the child included in the study was delivered in a health care facility, and 65% of the mothers were still breastfeeding their children. The other results presented in Table 3 (pooled analysis) show that only 61% of

the mothers initiated breastfeeding within 1 hour after childbirth, whereas the others initiated breastfeeding after 1 hour (35%). The initiation period varied significantly with maternal age (χ2 = 67.76; P = .00). The main reasons leading to failure to initiate breastfeeding within 1 hour after delivery were the following: insufficient milk production, maternal exhaustion from the childbirth process, and child-related factors such as sickness and inability to suck the breast. Although most caregivers (61%) initiated breastfeeding within 1 hour after delivery, a large number (32%) also gave their child other feeds such as home made sugar water, glucose water bought from drug stores, other fluid mixtures consisting of water with ghee, dry tea, or plain water. Only 34% of the children younger than 6 months of age were exclusively breastfed according to recommendations. Complementary Feeding Practices

At the time of the study, the majority of the caregivers (94.4%) had started

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Table 2. Characteristics of the Caregivers and Their Children Variable

N = 232; n (%)

Age of caregiver in years (M = 27.4, SD =8.2)

Less than 20 years

36 (15.5%)

20-29 years 30-39 years 40-49 years More than 50 years Relationship of caregiver to the child

122 (52.6%) 55 (23.7%) 13 (5.6%) 6 (2.6%)

Biological caregiver Grandmother Caregivers’ level of education No formal education Primary Secondary Tertiary Marital status of caregiver Married Divorced Widowed Separated Number of children in the household (M = 1.2, SD = 0.4) 1-2 3-5 Main source of income for the household Farming Small business Money or aid that is received from a relatives Others

226 (97.4) 6 (2.6%)

Gender of the child Male Female Age of child in months (M = 12.6; SD = 6.5) 0-6 7-11 12-24

24 (10.3%) 144 (62.1%) 57 (24.6%) 7 (3.0%) 194 (83.6%) 16 (6.9%) 10 (4.3%) 12 (5.2%) 185 (79.7%) 47 (20.1%) 160 (69.0%) 58 (25.0%) 3 (1.3%) 11 (4.7%) 115 (49.6%) 117 (50.4%) 56 (24.1%) 60 (25.9%) 116 (50.0%)

Prevalence of malnutrition

Wasting (WLZ; M = −0.09, SD = 0.96)



Underweight (WAZ; M = −0.78, SD = 1.03)

25 (10.8%)



Stunting (LAZ; M = −1.36, SD = 1.11)

62 (26.7%)



Normal nutrition status

5 (2.2%)

140 (60.3%)

Abbreviations: M, mean; SD, standard deviation; WLZ, Weight for Length z-score; WAZ, Weight for Age z-score; LAZ, Length for Age z-score.

feeding their child with other feeds, and 57% started the complementary feeding before the recommended 6 months of age. The mean age at which complementary feeds were introduced to the child was 2.9 ± 0.8 months. The caregivers reported that they gave their children solid foods and fluids or semisolids such as plain milk, milk tea, dry tea, and porridge. Most caregivers did not take into consideration the age appropriateness of the feeds, and there was no proper transition time from liquids to semisolids and to solid feeds as recommended. The majority of the caregivers introduced solid foods at the age of 6 months, and the most commonly used complementary foods were maize porridge, millet porridge, and cassava flour porridge. Only 27% of the participants reported using millet porridge during the weaning period. Other Infant and Young Child Feeding Practices and Quality of Diet

Results presented in Table 4 show that children aged 6 to 9 months received more meals in a day compared with 12- to 24-month-old children. The proportion of children fed with animal protein–rich foods reduced with increasing age of the child. A larger number of caregivers (49%) reported that children aged 6 to 24 months were served food on their own plates, and only 26% received assistance with feeding from adults. The results show that the majority of the children in the age group of 9 to 12 months (94.4%) and 6 to 9 months (87%) had medium scores on the CFI. The majority of children in the age group of 12 to 24 months (68%) had low CFI scores, indicating poor IYCFP practices. The mean CFI score across all age groups was 3.63 ± 1.47, which also shows generally poor IYCFPs by caregivers included in the sample. Feeding Practices Associated With Poor Nutrition Outcomes

The CFI scores of caregivers were analyzed to examine differences in nutrition outcomes of the children. Statistically

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Table 3. Timing of Initiation of Breastfeeding and Types of Prelacteal Feeds Given

Breastfeeding Practices

National Value Percentage, UDHS (2006)

n (%)

Initiation of breastfeeding Within 1 hour after delivery Within a day

141 (60.8%)

42.2%

73 (31.5%)

43.9%

Never breastfed

7 (3.0%)



I don’t remember

11 (4.7%)



Child-related factors

20 (8.6%)



Insufficient milk production

61 (26.3%)



Maternal exhaustion

10 (4.3%)



141 (60.8%)



Reasons for not starting to breastfeed within the first hour of birth

Initiated breastfeeding within 1 hour Prelacteal feeds given Glucose water

17 (7.3%)

31%

Sugar water

42 (18.1%)

31%

Tinned milk

10 (4.3%)