Central Journal of Human Nutrition & Food Science

Cite this article: Sultana S, Hoque A, Saleh F (2014) Infant and Young Child-feeding Practices and their Nutritional Status in a National Nutrition Programme Area in Bangladesh: A Cross-Sectional Study. J Hum Nutr Food Sci 2(2): 1028.

*Corresponding authorSharmin Sultana, Department of Community Nutrition, Bangladesh University of Health Sciences, Darus Salam, Mirpur 1, Dhaka 1216, Golden Dreams Apartment, F-2A,H-395-396, R-6, Baitul Aman Housing Society, Adabor, Dhaka-1207, Bangladesh, Tel: 01817109223; Email:

Submitted: 12 October 2013

Accepted: 09 April 2014

Published: 12 April 2014

ISSN: 2333-6706

Copyright© 2014 Sultana et al.

OPEN ACCESS

Research Article

Infant and Young Child-feeding Practices and their Nutritional Status in a National Nutrition Programme Area in Bangladesh: A Cross-Sectional StudySharmin Sultana*, Asirul Hoque, and Farzana SalehDepartment of Community Nutrition, Bangladesh University of Health Sciences, Bangladesh

INTRODUCTIONAppropriate feeding practices are essential for the nutrition,

growth, development, and survival of infants and young children [1]. A proper feeding practice helps a baby grow healthy and well-nourished whereas an inappropriate feeding practice may cause various diseases and may result in malnutrition.

Infants should be breastfed within half an hour of birth, exclusively breastfed for the first six months of life, and thereafter should receive nutritionally-adequate and safe complementary foods while breastfeeding continues up to two years and beyond [1].

Worldwide, an estimated 34.8% of infants are exclusively breastfed for the first six months of life, and the majority receives some other foods or fluids in the early months [2].

Complementary foods are often introduced either too early or too late and are often nutritionally inadequate and unsafe [3]. In Bangladesh, 43% of children are breastfed within one hour of birth [3]. Although the rate of colostrum feeding has improved (92%) in the past decade [3], the rate of prelacteal feeding did not (62%) [3]. Only 43% of infants aged less than six months are exclusively breastfed, and the remainders are given water, other milk, and other liquids in addition to breast milk. The rate of complementary feeding among children aged 6-9 months is 74% [3].

In Bangladesh, the National Nutrition Programme (NNP) was a programme of the Ministry of Health and Family Welfare. Under this programme, the Ministry provided support to children, pregnant women, breastfeeding mothers, newly-married women, and adolescent girls [4]. Although the NNP claimed to have

Abstract

Background: In developing countries, around 32% of under-five children are stunted, and 10% are wasted. Sub-optimal breastfeeding and inappropriate complementary feeding practices are among the causes of malnutrition.

Objectives and Methods: This cross-sectional study assessed the infant and young child-feeding practices and their nutritional status in Kapasia under Gazipur district, Bangladesh. In total, mothers of 150 under-two children were purposely selected.

Results: Among the mothers, 67.3%, 82.7%, and 98% initiated breastfeeding within one hour, maintained exclusive breastfeeding, and continued breastfeeding respectively. The rate of the timely starting of complementary feeding was 83.1%. Among the children, 16%, 8.3%, and 26.7% had moderate (-2.01 to -3 SD) underweight, wasting, and stunting respectively. Whereas severe (<-3SD) underweight, wasting, and stunting were 6.0%, 3.3%, and 5.0% respectively.

Conclusion: The study demonstrated that infant and young child-feeding practices and their nutritional status were good; however, mothers should be encouraged to use various types of foods.

Keywords•Infant-feeding practices•Young child-feeding practices•Infant nutritional status•Child nutritional status•Cross-sectional studies•National Nutrition Programme•Bangladesh

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achieved better results compared to the non-NNP areas, the claim has not been substantiated with robust analysis of evidence. The aim of the present study was, therefore, to assess the infant and young child-feeding (IYCF) practices and the infant and young child nutritional status in a specific NNP area in Bangladesh.

MATERIALS AND METHODSThis cross-sectional study was conducted in Kapasia under

Gazipur district, Bangladesh. Mothers of 150 under-two children were purposively selected. The study subjects did not include those children who were suffering from chronic and serious illness. Only one under-two child of each mother was selected for the study.

A semi-structured questionnaire, developed following the guidelines of the World Health Organization (WHO) for complementary feeding, was used for conducting face-to-face interviews. The questionnaire contained sociodemographic status (education, income, occupation, housing condition), breastfeeding and complementary feeding status, hygiene and sanitation related issues. To recall the name and the amount of food given to the baby, a 24-hour recall method was used. The frequencies of foods offered to children per day and per week were also recorded. Quantity of food was measured using measuring cups and bowls, and frequencies of food intake were recorded by adjudging how many times an item of food were given to a child in a day or in a week. The total energy intake of a child was calculated using the formula of calculating cooked food energy from raw food energy.

The following definitions of exclusive breastfeeding, complementary feeding, and responsive feeding were followed in the study:

Exclusive breastfeeding means that an infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements, or medicines.

Complementary feeding means giving extra food to the child along with breast-feeding after the completion of six months of age.

Responsive feeding means feeding slowly and patiently, and encouraging children to eat without any force. Feeding times are periods of learning and love, talk to children during feeding, with eye-to-eye contact. Here washing hand or utensil properly means washing with soap.

For anthropometric measurements, lengths of the babies were measured using a locally-manufactured, collapsible length board, which was precise to 1 mm. Weights were measured using an electronic scale, which was precise to 10 g (UNICEF Uniscale; SECA Gmbh & Co, Hamburg, Germany). The z-score was used for measuring the nutritional status of children. According to the WHO z-score classification of anthropometric indicators, height-for-age, weight-for-height, and weight-for-age were used for measuring stunted, wasted, and underweight infant and young children respectively. Data were collected in March 2011. The feeding practices of 71 children who were offered complementary food were measured.

Before conducting the study, a detailed protocol was submitted to the local review committee for approval. The researcher obtained verbal consent from each and every respondent by reading out the consent form before them before interview.

The χ2 test was done to find out the association among qualitative variables (sociodemographic status, breastfeeding practices, and nutritional status) using the SPSS software (version 11.5), and the p value (0.05) was considered the level of significance.

RESULTSSocio demographic characteristics

Of the 150 children, 46% were boys, and 54% were girls. Ninety percent of the respondents were Muslim, and 10% were Hindu. Their mean [±Standard Deviation (SD)] birth weight was 2.8±.3kg. The mean (±SD) age of the mothers was 25.3±4.7 years. Of the children, 52.7% were aged 0-6 months, and 47.3% were aged 6-23 months (Table 1).

Breastfeeding

Of the mothers, 67.3% initiated breastfeeding within one hour of birth (Table 2). Most (82.7%) mothers offered exclusive breastfeeding to their children (Table 3). Breastfeeding was continued for 98% of the children (Table 4).

Complementary feeding

The early introduction (before 6 months) of complementary feeding to children aged 6-23 months was 16.9%. The timely starting of complementary feeding was 83.1% (Table 5).

Of the mothers, 24% fed their children slowly and patiently, 45% talked to them during feeding, and 17% forced them to eat (Figure 1).

Characteristics %

Age (months) of children

0-6 52.7

6-8 10.6

9-11 8.7

12-23 28.0

Sex of children

Male 46.0

Female 54.0

Occupation of mothers

Housewife 95.3

Others 4.7

Occupation of fathers

Business 39.3

Farming 18.7

Mason and day labor 5.3

Others 36.7

Table 1: Sociodemographic and economic characteristics (n=150).

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Age (months)Initiation of breastfeeding

Within 1 hour%

> 1 hour%

0-6 69.6 30.4

6-8 68.7 31.3

9-11 84.6 15.4

12-23 57.1 42.9

Total 67.3 32.7

Table 2: Initiation of breastfeeding (n=150).

Age (months)Exclusive breastfeeding (0-6 mo)

Yes%

No%

0-6 79.7 20.3

6-8 87.5 12.5

9-11 84.6 15.4

12-23 85.7 14.3

Total 82.7 17.3

Table 3: Pattern of exclusive breastfeeding (n=150).

Age (months)Continuation of breastfeeding

Yes%

No%

0-6 100 0

6-8 100 0

9-11 92 8

12-23 95 5

Total 98 2

Table 4: Continuation of breastfeeding (n=150).

Age (months)Complementary feeding statusEarly

%Timely

%6-8 6.3 93.8

9-11 23.1 76.9

12-23 19.0 80.9

Total 16.9 83.1

Table 5: Complementary feeding status of children (n=71).

24.0

45.0

17.0

3.011.0

Feeding slowly

Talking during feeding

Forcing child to eat

Helping child to eat

Others

Figure 1 Strategy to attract children to feed (n=71).Results were expressed as %

About 76% of the mothers washed their hands properly, and 11.3% washed both hands and utensils properly. 91.5% used soap after toilet use. 34% used bottle for feeding (Table 6).

The intake of energy of ≥200 kcal/day in the age-group of 6-8 months was 93.7% and <200 kcal/day was 6.3%. The intake of energy of ≥300 kcal/day in the age-group of 9-11 months was 92.3% and <300 kcal/day was 7.7%. The intake of energy of ≥550 kcal/day in the age-group of 12-23 months was 52.4% and <550 kcal/day was 47.6%.

The consumption of rice and khichuri was higher compared to meat, fish, and egg. Of the children, 35.2% took potato once a day. Fish was taken by 26.7% of the children, and meat was taken by 36.6% per week while 18.3% took egg 3-6 times a week (Table 7). Only 1.4% took green-leafy vegetables daily (Table 8).

Nutritional status

Of the children, 6.0% were severely underweight, 6.0% were moderately underweight, 3.3% were severely wasted, and 8.3% were moderately wasted. 5% were severely stunted, and 26.7% were moderately stunted (Table 9).

A significant association (χ2=11.247, df=2, p=0.004) was found between education of mothers and exclusive breast feeding (Table 10) and between sex and stunting of children (χ2=15. 005, df=2, p=0. 001) (Table 11).

Steps taken by mothers %

Hand and utensil-washing practices

Washed hands properly 76.0

Washed utensils properly 5.6

Washed hands and utensils properly 11.3

Washed nothing 7.0

Reheating refrigerated foods before serving

Fridge not available 39.4

Not done 37.2

Reheated 58.1

Others 4.6

Keeping food covered after preparation

No 8.5

Yes 91.5

Hand-washing after toilet use

Soap 91.5

Ash 3.0

Nothing 4.0

Other 1.5

Type of utensil used

Bottle 34

Cup 26.6

Other 39.4

Table 6: Steps taken by mothers for maintaining hygiene before feeding (n=71).

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Food item >1 time/day%

1 time/day%

3-6 times/ week%

1-2 times/ week%

Never%

Infant formula Milk 12.7 1.4 0 0 85.9

Cow/goat milk 15.4 14.1 12.6 4.2 53.5

Egg 0 8.5 18.3 9.8 63.4

Fish 1.4 2.8 21.1 26.7 47.9

Meat 0 0 1.4 36.6 62.0

Dal 19.7 22.5 8.4 0 49.3

Table 7: Consumption of foods by protein group of children (n=71).

Food item >1 time/day%

1 time/day%

3-6 times/ week%

1-2 times/week%

Never%

Pumpkin 0 0 11.2 (5.6 83.1

Ripe papaya 0 0 5.6 4.2 90.1

Palong shak 0 0 2.8 2.8 94.4

Kochu shak 0 1.4 5.6 4.2 88.7

Pui shak 0 1.4 7.0 4.2 85.9

Banana 2.8 12.7 21.1 16.9 46.5

Carrot 0 2.8 5.6 4.2 87.3

Table 8: Consumption of fruits and vegetables by children (n=71).

Anthropometric indicator

Nutritional statusNormal

(-2 to +2)%

Moderate(-3 to -2.01)

%

Severe (<-3)%

Weight-for-age 78.0 16.0 6.0

Weight-for-length 88.3 8.3 3.3

Length-for-age 68.3 26.7 5.0

Table 9: Nutritional status of children.

Education of mothersExclusive breastfeeding

Pearson’s χ2(df=2 ) P valueYes

%No%

Illiterate 80.0 20.0

11.247 0.004Primary 94.0 6.0

Higher 73.0 27.0

Table 10: Sociodemographic factors and exclusive breastfeeding (n=150).

Sociodemographic factor

Nutritional statusPearson’s χ2

(df=4 ) P valueNormal

%

Moderatestunting

%

Severe stunting%

Male 42.3 46.1 11.6 15.005 0.001

Female 88.2 11.8 0

Table 11: Socio demographic factors and IYCN (n=60).

DISCUSSIONIn the present study, 67.3% of the mothers initiated

breastfeeding within one hour of birth. In Bangladesh, overall, 43% of infants are breastfed within one hour of birth [3]. Data from the NNP baseline survey showed that 27.7% of mothers initiated breastfeeding immediately after birth, and 50.9% initiated within 24 hours of birth. A survey of the Bangladesh

Integrated Nutrition Programme shows that 34.1% of mothers initiated breastfeeding immediately after birth whereas 49.9% initiated breastfeeding within 24 hours of birth [5].

In our study, the rate of initiation of breastfeeding was high (67.3%) because of the intervention used. Results of a study in Ghana showed an association between the timing of breastfeeding and the survival of newborns [6]. The study showed that 22% of

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all neonatal deaths could be prevented if all women would have initiated breastfeeding within one hour of birth [6].

The present study found that 82.7% of the mothers exclusively breastfed their children. Data from the NNP baseline survey showed that the rate of exclusive breastfeeding to infants aged 0-6 months was 11.7%. Whereas the survey of the BINP showed that it was only 8.1% [5]. Exclusive breastfeeding for six months confers several benefits to the infant and the mother. According to the WHO growth standards, exclusively-breastfed children have more rapid growth in the first six months of life compared to infants of other age-groups [2].

Ninety-eight percent of the study mothers continued breastfeeding. According to the Bangladesh Demographic and Health Survey, 98% of children receive continued breastfeeding [3], which is similar to the findings of the present study.

In the present study, 83.1% of the children, aged 6-23 months, were offered complementary feeding at the appropriate time. Results of a study in an urban area of Bangladesh showed that about 60% of mothers initiated complementary feeding before six months of age [7].

Introduction of complementary feeding before six months of age is not advisable. Results of studies in Malawi revealed that children who were given foods according to the time schedule recommended by the WHO were found to be well-nourished compared to children who received complementary feeding early [8]. Results of a study in Bangladesh showed that 80.8% of women were unaware of the appropriate age of complementary feeding [9]. In the present study, the rate of early starting of complementary feeding was 16.9%.

The practice of responsive feeding, applying the principles of psychosocial care during feeding, is one of the important issues. In this study, 24% of the children were fed slowly and patiently, 45% of the mothers talked to their children during feeding, and 17% forced their children to eat. Several intervention studies that included feeding behaviors as part of the recommended practices reported positive effects on child growth [10].

Only 11.3% of the study mothers washed both hands and utensils properly; however, 76% washed their hands properly, which may be considered satisfactory. In Bangladesh, only 26.7% of people wash their hands with water, soap, or ash after defecation, and 3% wash their hands with soap and water before having a meal, feeding children, and preparing food [11]. A study in Central America identified that improved hand-washing can prevent the occurrence of diarrhoea remarkably consistent in various settings [12].

Thirty-four percent of the study mothers used bottles for feeding their children. Due to associated exposures to pathogens and interference with successful breastfeeding, the current recommendation strongly discourages the use of baby bottles throughout childhood [13]. In the present study, commonly-consumed complementary foods among different age-groups of children included rice, suzi, and khichuri. Green-leafy vegetables, fruits, fish, and meat were not consumed daily. 47.6% of the study children were given <550 kcal/day at 12-23 months of age.

Of the children, 16.0% were moderately underweight, 8.3%

were moderately wasted, and 26.7% were moderately stunted. 6% were severely underweight, 3.3% were severely wasted, and 5.0% children were severely stunted. In the study, the cause of malnutrition could be the early introduction of complementary food. Unhygienic household condition and infection may also be a cause.

The χ2 test demonstrated a significant association between education of mothers and exclusive breastfeeding. There was a high difference in the rate of exclusive breastfeeding among the literate and illiterate mothers. A study in Mexico has shown that lack of education among many caregivers may hinder their ability to give care to their children [13]. A more-educated mother/caregiver raises a better- developed child in terms of mental and physical development compared to a less-educated mother, which also enhances the efficient use of time of mother or caregiver [13].

LIMITATIONSSince the study was done for academic purpose, the nearest

NNP area was selected due to shortage of time. The study was done on a limited sample, which might not represent the overall population. Due to some limitations, heights of all children were not measured. Heights of 60 children were, however, measured.

CONCLUSIONBased on the findings, it can be concluded that the IYCF

practices and the nutritional status of the majority of the children were good. The findings suggest that mothers should be educated about the importance of use of various foods, and awareness should be created among them about the danger of offering bottle-feeding. Mothers should also be encouraged for general education as the level of education influences the feeding practices and nutritional status. Since malnutrition was higher among male children compared to female children in the study area, further study is needed to identify the causes of malnutrition among male children.

ACKNOWLEDGMENTThe authors thank Mr. M. Shamsul Islam Khan, Advisor,

Department of Library, Bangladesh University of Health Sciences, for his guidance in language editing. Finally, they express their deepest gratitude and thanks to the respondents for their valuable time and co-operation and appreciate the support of National Nutrition Programme workers.

REFERENCES1. Bangladesh Directorate General of Health Services. National strategy

for infant and young child feeding in Bangladesh. Dhaka: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh. 2007; 60.

2. World Health Organization. Infant and young child feeding-model chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization. 2009; 99.

3. National Institute of Population Research and Training, Mitra and Associates, and Macro International. Bangladesh demographic and health survey 2007. Dhaka: National Institute of Population Research and Training, 2009; 381.

4. Policy brief-Nutrition in Bangladesh, Jones & Bartlett Learning, LLC.

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Sultana et al. (2014)Email:

J Hum Nutr Food Sci 2(2): 1028 (2014) 6/6

2010.

5. National Institute of Population Research and Training, ICDDR, B: Centre for Health and Population Research, Institute of Public Health Nutrition. National Nutrition Programme baseline survey 2004 report. Dhaka: International Centre for Diarrhoeal Disease Research, Bangladesh 2005. 319.

6. Dadhich JP, Agarwal RK. Mainstreaming early and exclusive breastfeeding for improving child survival. Indian Pediatr. 2009; 46: 11-17.

7. Hassan MQ, Hannan A, Kabir ARML, Barua PC, Rahman AKMF, Rahman A et al. Infant and young child feeding practices in urban areas of Bangladesh (abstract). Khan MSI, Rahim MA, Ahmed T, editors. In: Combating malnutrition and intestinal disease in children: are we doing enough? Abstracts book [of the] 8th Commonwealth Congress on Diarrhoea and Malnutrition, 6-8 February 2006, ICDDR,B, Dhaka. Dhaka: International Centre for Diarrhoeal Disease Research, Bangladesh. 2006; 20.

8. Madise NJ, Mpoma MO. Child malnutrition and feeding practices in

Malawi. Food Nutr Bull. 1997; 18: 190-201.

9. Killewo J, Alam N, Gausia K, Ahmed F, Yunus M, Chakraborty J, et al. Determinants of exclusive breast-feeding in a rural area of Bangladesh. Dhaka: ICDDR,B: Centre for Health and Population Research. 2002.

10. Pan American Health Organization. Guiding principles for complementary feeding of the breastfed child. Washington. DC: Pan American Health Organization, 2003; 37.

11. NGO Forum for Drinking Water Supply and Sanition. WatSan information booklet.

12. Saade C, Bateman M, Bendahmane DB. The story of a successful public-private partnership in Central America: hand washing for diarrheal disease prevention. Arlington, Virginia: Basic Support for Child Survival Project, Environmental Health Project. 2001:11.

13. Matthew AK, Amodu AD, Sani I, Solmon SD. Infant feeding practices and nutritional status of children in north western Nigeria. Asian J Clin Nutr. 2009; 1: 12-22.

Sultana S, Hoque A, Saleh F (2014) Infant and Young Child-feeding Practices and their Nutritional Status in a National Nutrition Programme Area in Bangladesh: A Cross-Sectional Study. J Hum Nutr Food Sci 2(2): 1028.

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