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. 2024 Mar 6;19(3):e0299969. doi: 10.1371/journal.pone.0299969

Appropriate complementary feeding practice and associated factors among mothers of children aged 6–23 months in Bhimphedi rural municipality of Nepal

Thag Bahadur Gurung 1, Rajan Paudel 2, Anil K C 3,*, Aashish Acharya 4, Pravin Kumar Khanal 5
Editor: Naveed Sadiq6
PMCID: PMC10917259  PMID: 38446802

Abstract

Background

Appropriate complementary feeding plays a crucial role in the enhancement of child survival; and promotes healthy growth and development. Evidence has shown that appropriate complementary feeding is effective in preventing malnutrition and child mortality. Thus, the main objective of this study is to assess the prevalence of appropriate complementary feeding practice and associated factors among mothers of children aged 6–23 months.

Methodology

A community-based cross-sectional study was conducted from August to December 2018. A total of 259 mothers who had children aged 6–23 months were selected randomly from the 714 eligible mothers. A structured questionnaire was used to collect the data from the respondents. The data were collected in a tablet phone-based questionnaire using the Open Data Kit mobile application by face-to-face interview. Data analysis was done in SPSS version 21. Multivariable logistic regression was used to identify the factor associated with appropriate complementary feeding practice.

Result

The prevalence of appropriate complementary feeding practice was 25%. Mother and father with formal education (AOR 6.1, CI: 1.7–22.4 and AOR 5.6 CI: 1.5–21.2 respectively), counseling on IYCF (AOR 4.2, CI: 1.5–12.3), having kitchen garden (AOR 2.4, CI: 1.1–5.2) and food secured family (AOR 3.0, CI: 1.0–8.9) had higher odds of appropriate complementary feeding practice.

Conclusion

This study revealed that a significant proportion of mothers had inappropriate complementary feeding practice for their children aged 6–23 months. This study highlights the need for behavior change communication and promotion of kitchen garden to address the associated factors and promote appropriate complementary feeding practice.

Introduction

After the age of six months, breast milk is not sufficient for the growth and development of the baby. The starting of other liquids and food along with breast milk to meet the nutritional requirement for the growth and development of the baby is known as complementary feeding [1, 2]. Appropriate child feeding has a crucial role in the enhancement of child survival; and promotes healthy growth and development, a productive future generation, and national development. Ensuring optimal nutrition during the first 2 years of a child’s life is fundamental to lowering morbidity and mortality, minimizing the risks of chronic diseases, and promoting better development in general [3]. Exclusive breastfeeding up to 6 months of age and breastfeeding up to 12 months of age occupied the number one position with the introduction of appropriate complementary feeding starting at 6 months of age holding number three in terms of their effectiveness in preventing child mortality. Almost, one-fifth of under-five mortality due to diarrhea and ARI were estimated to be prevented by these two interventions alone [4]. Undernutrition resulting from poor complementary feeding practice is responsible for 35% of under-five mortality [5].

South Asia region has the lowest rate of minimum meal frequency (47%), minimum dietary diversity (23%), and minimum acceptable diet (13%) in comparison to other regions [6]. Nepal Demographic and Health Survey Report 2016 revealed that only 46% of children aged 6–23 months received meals with the minimum recommended diversity), 71% received meals at the minimum frequency, and 36% met the criteria of a minimum acceptable diet [7].

A handful of studies were conducted in Nepal regarding the indicators of Infant and Young Child Feeding (IYCF) and associated factors. One study revealed that more than half of the children timely initiated complementary feeding at 6 months (57.5%) and achieved minimum dietary diversity (60%). The factors associated with complementary feeding were maternal education and occupation, and child characteristics such as birth order, and male gender [8]. Another study reported similar results i.e., only 57% of mothers initiated complementary feeding at the age of 6 months whereas 84% of children comply with minimum meal frequency and 35% of children comply with minimum meal diversity. Maternal education and having had their children’s growth monitored were significantly associated with complementary feeding practices [9]. These studies studied the indicators of IYCF and associated factors individually. So, a compressive study is needed to assess the revised individual and composite indicators of IYCF and associated factors. The current study aims to identify the prevalence of Minimum Meal Frequency (MMF), Minimum Dietary Diversity (MDD), Minimum Acceptable Diet (MAD), Timely Introduction of Complementary Feeding, Appropriate Complementary Feeding Practice (ACFP), and the factors associated with Appropriate Complementary Feeding Practice.

Methodology

Study design and setting

From August 2018 to December 2018 a cross-sectional study was conducted to assess the different indicators of complementary feeding and factors associated with appropriate complementary feeding practice in Bhimphedi Rural Municipality of Nepal. Bhimphedi rural municipality is one of nine municipalities of Makawanpur district of Bagmati province.

Study population and sampling

The study population was the mothers of children aged 6–23 months who were permanent residents of Bhimphedi Rural Municipality or stayed at Bhimphedi Rural Municipality for at least one year. There was a total of 714 children aged 6–23 months at the start of the study. The eligible numbers of participants were enlisted from the HMIS 4.2 (FCHV Register) and HMIS 2.2 (Immunization Register) of each health facility in the study area. The mother’s name of each child meeting the criteria was listed in the MS Excel 2016. The sample size was calculated by using the finite population correction formula with a 5% margin of error and 95% confidence level and taking the prevalence of minimum acceptable diet as 44% [7]. After adding a 5% non-response rate, the final sample size of 259 was calculated. The required sample size (n = 259) was drawn randomly by generating random numbers. The 259 research participants with the lowest random number were visited with the help of Female Community Health Volunteer (FCHV) and health workers for data collection.

Measures

Appropriate complementary feeding practice 6–23 months

Appropriate complementary feeding practice is the dependent variable and it is measured by using a composite indicator comprising three of the WHO core IYCF indicators. These are the timely introduction of solid, complementary feeding, minimum dietary diversity, and minimum meal frequency [10]. If a child fulfilled all three criteria, it was classified as having received appropriate complementary feeding [11].

Minimal diet diversity 6–23 months

Minimal Diet Diversity for 6–23 months of age is the consumption of foods and beverages from at least five out of eight defined food groups during the previous day. The eight food groups are breast milk; grains, roots, tubers, and plantains; pulses (beans, peas, lentils), nuts and seeds; dairy products (milk, infant formula, yogurt, cheese); flesh foods (meat, fish, poultry, organ meats); eggs; vitamin-A rich fruits and vegetables; and other fruits and vegetables [10].

Minimum meal frequency 6–23 months

Minimum meal frequency is the proportion of children between 6–23 months of age who received solid, semi-solid, or soft foods for at least the minimum number of times recommended by WHO. Breastfed children aged 6–8 months and 9–23 months of age should consume solid or semi-solid food minimum twice a day and thrice a day, respectively. Non-breastfed children between 6 and 23 months of age should consume solid or semi-solid food at least four times a day, and also, they should also intake dairy or formula milk [10].

Minimum acceptable diet 6–23 months

For breastfeeding children, MAD is defined as children receiving at least the minimum dietary diversity and minimum meal frequency for their age during the previous day; And for non-breastfed children, MAD is defined as children receiving at least the minimum dietary diversity and minimum meal frequency for their age during the previous day as well as at least two milk feeds [10].

Introduction of solid, semi-solid, or soft foods 6–8 months

The proportion of infants 6–8 months of age who consumed solid, semi-solid, or soft foods during the previous day [10].

Household food security

Food security is defined as a state in which “all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life” [12]. Household food security was assessed through the Household Food Insecurity Access Scale (HFIAS). There are altogether nine questions. Each question is asked with a recall period of four weeks. The respondent is first asked whether the condition in the question happened at all in the past four weeks. If the respondent answers “yes, a frequency-of-occurrence question is asked to determine whether the condition happened rarely (once or twice), sometimes (three to ten times), or often (more than ten times) in the past four weeks [13].

Data collection

A structured questionnaire was used to collect the data from the research participants. The researcher himself was involved in the data collection and the process was closely supervised by an academic supervisor. The data were collected in a tablet phone-based questionnaire using the Open Data Kit (ODK) mobile application from 24 October 2018 to 5 November 2018.

Data management and analysis

The collected data were assessed for completeness and consistency of information and uploaded to the Open Data Kit server on a daily basis. The compiled data were first exported to IBM SPSS version 21 for cleaning and analysis. The outcome variable was coded as ‘1’ for appropriate complementary feeding practice and ‘0’ for inappropriate complementary feeding practice. Descriptive statistical analysis was performed to compute the frequency, and percentage for nominal data and mean for continuous independent variables. Binary logistic regression was performed to determine the relationship of each independent variable with appropriate complementary feeding practice. Multivariable logistic regression was done to examine the relationship between independent variables and appropriate complementary feeding practice to address the confounding effect. Only those variables that were significant at a 5% level of significance in bivariate analysis were included in the multivariable logistic regression analysis. Hosmer and Lemeshow test was used to test the goodness-of-fit for regression models. The test statistic was 0.80 (p > 0.05) which showed that the model adequately fit the data.

Ethical consideration

Ethical approval was taken from the Institutional Review Board (IRB) of the Institute of Medicine. Formal permission was also taken from the office of the respective rural municipality. The purpose of the study was clearly explained to the respondents and written consent was obtained from the study participants before collecting data. Those participants who were not practicing appropriate complementary feeding practice were provided with the correct information and advice was given to consult with Female Community Health Volunteers (FCHVs) and health workers at any point of service outlets during data collection.

Results

Fig 1 shows the prevalence of indicators of complementary feeding of children aged 6–23 months. The overall prevalence of appropriate complementary feeding practice of mothers of children aged 6–23 months was 25%. Four out of five mothers had initiated complementary feeding to their children at the age of six to eight months. Seventy-one percent of the mothers met the WHO-recommended MMF, according to the age and breastfeeding status of the children. Similarly, 37% of mothers offer their children five or more types of food out of eight food groups. The prevalence of minimum acceptable diet for children aged 6–23 months was 27%.

Fig 1. Indicators of complementary feeding of children aged 6–23 months (n = 259).

Fig 1

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Table 1 depicts that the mean age of the mother and child was 27.1 years (SD 7.0 years) and 13.7 months (SD 4.7 months) respectively. Among the children majority (56.8%) were female. More than two-thirds (69.9%) of mothers had formal education whereas the remaining mothers were illiterate or literate only. Similarly, about three-fourths (73.7%) of fathers had attended formal education. Around 60% of the participants had five or fewer family members in their house. Out of the total respondents, 27.4% had paid jobs. Four-fifth (80.3%) of the participants had a family income below 32000 Nepalese rupees per month. Around three-fourths (73.0%) of mothers and their husbands decide on the type of food they eat. Sixty-three percent of the mothers had received counseling on IYCF. More than half (52.1%) of mothers had given birth to their child in the health facility. Only one-fourth of respondents had a kitchen garden in their homes. Sixty-eight percent of the families belonged to food-secured families.

Table 1. Socio-demographic, economic, and health service-related characteristics of the research participants.

Variable Number (n = 259) Percentage (%)
Age of mother
< 25 years 104 40.2
≥ 25 years 155 59.8
Mean (SD) 27.1 (7.0)
Age of child    
<12 months 102 39.4
≥12 months 157 60.6
Mean (SD) 13.7 (4.7)
Sex of baby
Male 112 43.2
Female 147 56.8
Education of mother
Formal education 181 69.9
No formal education 78 30.1
Education of father
Formal education 191 73.7
No formal education 68 26.3
Number of family members
≤ 5 154 59.5
> 5 105 40.5
Mean (SD) 5 (2)
Job of mother
Paid 71 27.4
Unpaid 188 72.6
Monthly income
< 32000 208 80.3
≥ 32000 51 19.7
Median (lowest-highest) 20,000 (6,000–100,000)
Decision for food
Wife and husband 189 73.0
Other family member 70 27.0
Counselling on IYCF
Yes 163 62.9
No 96 37.1
Place of delivery
Home 124 47.9
HFs 135 52.1
Kitchen garden
Yes 66 25.5
No 193 74.5
Household food security status
Secure 176 68.0
Insecure 83 32.0
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Table 2 shows the bivariate and multivariate regression analysis of dependent and independent variables. In bivariate analysis, the education of the mother, education of the father, number of family members, monthly income of the family, counseling on IYCF, place of delivery, presence of kitchen garden, and household food security status were found to be associated with appropriate complementary feeding practice.

Table 2. Factors associated with the appropriate complementary feeding practice.

 Variables Appropriate complementary feeding practice COR (95% CI) AOR (95%CI)
No (n = 194) Yes (n = 65)
Education of mother    
Formal education 119 (65.7%) 62 (34.3%) 13.0 (3.9–43.0)* 6.1 (1.7–22.4)*
No formal education 75 (96.2%) 3 (3.8%) Ref Ref
Education of father 
Formal education 129 (67.5%) 62 (32.5%) 10.4 (3.1–34.4)* 5.6 (1.5–21.2)*
No formal education 65 (95.6%) 3 (4.4%) Ref Ref
Number of family members    
≤ 5 108 (70.1%) 46 (29.9%) 1.9 (1.1–3.5)* 1.0 (0.5–2.2)
> 5 86 (81.9%) 19 (18.1%) Ref Ref
Monthly family income    
≥ 32000 26 (51.0%) 25 (49.0%) 4.0 (2.1–7.7)* 2.1 (0.9–4.9)
< 32000 168 (80.8%) 40 (19.2%) Ref Ref
Counselling on IYCF    
Yes 103 (63.2%) 60 (36.8%) 10.6 (4.1–27.5)* 4.2 (1.5–12.3)*
No 91 (94.8%) 5 (5.2%) Ref Ref
Place of delivery    
Health facility 89 (65.9%) 46 (34.1%) 2.9 (1.6–5.2)* 0.9 (0.4–2.1)
Home 105 (84.7%) 19 (15.3%) Ref Ref
Kitchen garden    
Yes 39 (59.1%) 27 (40.9%) 2.8 (1.5–5.2)* 2.4 (1.1–5.2)*
No 155 (80.3%) 38 (19.7%) Ref Ref
Household food security status    
Secure 116 (65.9%) 60 (34.1%) 8.1 (3.1–21.0)* 3.0 (1.0–8.9)*
Insecure 78 (94.0) 5 (6.0%) Ref Ref
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*P<0.05

In multivariate analysis, mother and father with formal education (AOR 6.1, CI: 1.7–22.4 and AOR 5.6 CI: 1.5–21.2 respectively), counseling on IYCF (AOR 4.2, CI: 1.5–12.3), having kitchen garden (AOR 2.4, CI: 1.1–5.2) and food secured family (AOR 3.0, CI: 1.0–8.9) had positive association at 95% CI with the appropriate complementary feeding practice.

Discussion

Appropriate complementary feeding during 6–23 months of life plays a crucial role in children’s growth, development, and survival. This study finds that the appropriate complementary feeding practice was 25% which is lower than the study done in Oromia-Ethiopia 30% [14], North West Ethiopia 37.2% [15], and higher than the study done in Northern Ghana 15.7% [16], Southwestern Nigeria 4.2% [17], and South Ethiopia 8.5% [18]. This variation in the prevalence of appropriate complementary feeding practice might be attributed to the cultural, and socio-economic status and the time of information collection among countries.

In this study, 82% of mothers of children aged 6–23 had initiated complementary feeding at the age of 6–8 months. This finding is consistent with the findings from Nepal Demographic Health Survey 2016 [7], and higher than similar studies done in Ethiopia [11, 19] and Bangladesh [20]. Out of the research participants, 71% of the children received an appropriate frequency of complementary food as per the WHO recommendation. The finding of this study is consistent with the findings from the Nepal Demographic Health Survey 2016 [7], Southern Ethiopia [11]. However, the finding is higher than the study done in Ethiopia [21], Northern Tanzania [22] and Bangladesh [20]. It was found that thirty-seven percent of mother offer at least five groups of food out of eight food groups to their children. This finding is higher than the study done in Ethiopia [21], Pakistan [23], and Bangladesh [20] and lower than Srilanka [24] and Oromia-Ethopia [14]. Similarly, 27% of children aged 6–23 months received a minimum acceptable diet. The finding is lower in comparison to the findings of NDHS-2016 [7], Oromia- Ethiopia [14], Bangladesh and Sirlanka [24]. It might be because most of the population relies on certain local staple foods like rice, wheat, potatoes, etc. Although children are fed at regular interval, the variety of food options is low. Furthermore, there is a pervasive cultural view in Nepal that cereal meals contain high energy and are sufficient for child growth, dismissing the value of a diverse diet. [9].

In multivariable logistic regression, maternal education shows a significant association with appropriate complementary feeding practice. Mothers who had attended formal education had higher odds of practicing appropriate complementary feeding practice than those who were illiterate or literate only (AOR 6.1, CI: 1.7–22.4). This finding is consistent with similar studies conducted in Ethiopia and Uganda [11, 25]. This could be due to educated mothers have greater confidence, a higher position within the household, and more ability to allocate household resources on their own compared to mothers with no schooling [26]. Educated mothers also can understand and internalize the behavior change communication message regarding complementary feeding and apply it in their daily life.

The involvement of the father is equally important while taking care of the child. Taking into consideration of patriarchal nature of Nepalese society men are conventionally considered responsible for major decisions within the households on many occasions as compared to their female counterparts [27]. In this situation, educated husbands can better understand and support their wives by approving what mothers would like to do to keep their children healthy. Educated husbands might enhance the wife’s awareness of the timely initiation of complementary feeding to their infant [19]. Like the mother, an educated father also can understand and internalize the behavior change communication message regarding complementary feeding and support the mother to comply with appropriate complementary feeding practice. This study showed a positive association between the father’s education and appropriate complementary feeding practice (AOR 5.6, CI: 1.5–21.2). This finding is supported by similar studies done in China [28] and Southwest Ethiopia [19].

Comprehensive information regarding complementary feeding motivates mothers to practice appropriate complementary feeding by increasing their knowledge regarding IYCF and helping to overcome the difficulties. In Nepal, counseling on IYCF was done during childbirth, PNC visits, growth monitoring, and immunization. The repeated information will encourage mothers to follow the appropriate complementary feeding practice as per the age of the baby. Even FCHV provides mothers with information regarding IYCF as per the age of the baby. This study identified that the mothers who received counseling on IYCF had higher odds of practicing appropriate complementary feeding (AOR: 4.2, CI: 1.5–12.3) in compression to those who did not receive any counseling. This finding is supported by studies done in Ethiopia [14, 15, 29], Nepal [9], and Nigeria [30].

The best place to find an array of fresh fruits and vegetables is the kitchen garden. The kitchen garden plays a crucial role in ensuring diverse food groups at the table as recommended by WHO. This study revealed that those families who had kitchen garden were two times more likely to follow appropriate complementary feeding practice in comparison to those who did not have kitchen garden (AOR 2.4, CI: 1.1–5.2).

Mothers who are from food-secure households were more likely to practice appropriate complementary feeding practice in compression to those who were from food-insecure house households (AOR 3.0, CI: 1.0–8.9). This finding is consistent with the study done in Ethiopia [14, 31, 32] and Bangladesh [20, 33]. This can be explained by the fact that food secured family has access to nutritious food throughout the year.

Some limitations need to be considered when interpreting the results of this study. One of the important limitations is recall bias because the information on IYCF indicators was collected on a single 24-hour recall basis. Seasonal variation and cultural factors were not assessed in this study which might have affected the type of food consumed by the infant and young child. Due to the cross-sectional nature of this study, conclusions on the cause-effect relationship cannot be drawn.

Conclusion

This study revealed that the prevalence of MDD and MAD were low. Similarly, a significant proportion of mothers had inappropriate complementary feeding practice for their children aged 6–23 months. Factors such as spouse education, counseling on IYCF, kitchen garden, and household food security had positive association with appropriate complementary feeding practice. To improve the appropriate complementary feeding practice, this study highlights the need for behavior change communication interventions for illiterate or literate-only parents. Similarly, efforts should be made to promote food diversity and food security to increase access to nutritious food for families. Encouraging the establishment of kitchen garden can be an effective strategy to improve MDD and complementary feeding practices.

Supporting information

S1 File

(SAV)

pone.0299969.s001.sav (31.7KB, sav)

Acknowledgments

Authors would like to express our gratitude to the faculty members of the Central Department of Public Health and Department of Community Medicine, Institute of Medicine, Tribhuvan University, Nepal, for their invaluable guidance throughout the course of our research project. We thank Mr. Dhruba Prasad Lamichhane, Health Coordinator of Bhimphedi rural municipality and Health Assistant, Mr. Dipesh Shrestha from Ipa Health Post for their support in establishing coordination at study sites, as well as to FCHV, and local health workers for their support during data collection. The authors would also like to express sincere thanks to all research participants for their valuable time and information.

Data Availability

All relevant data are within the manuscript and its supporting information files or can be found in https://doi.org/10.6084/m9.figshare.24633153.v1.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Naveed Sadiq

17 Nov 2023

PONE-D-23-31826Appropriate complementary feeding practice and associated factors among mothers of children aged 6-23 months in Bhimphedi rural municipality of NepalPLOS ONE

Dear Dr. K.C.,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. There are minor comments from the reviewers. Kindly address those to strengthen your manuscript on technical terms.

Please submit your revised manuscript by Jan 01 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Naveed Sadiq, Ph.D.

Academic Editor

PLOS ONE

Journal requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

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3. We are unable to open your Supporting Information file [Supporting Information.sav]. Please kindly revise as necessary and re-upload.

4. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. Line (L) 61-62: WHO recommended to continued breastfeeding up to 2 years of beyond not 12 months as stated. Any comment or justification on author's statement on this matter?

2. L61-65: The statement is not clear. Please paraphrase the statement to be clearer and what are on basis of this statement?

3. L88-89: I would suggest the author to consider to follow and standardised the indicator's name according to WHO Unicef IYCF indicator 2021. 'Introduction of solid, semi-solid or soft food 6-8 months (ISSSF)

4. L113-119: I would recommend the author to elaborate more on the selection of 3 indicators from 17 IYCF WHO IYCF practice's indicators. To justify why choose the three selected indicators and how classified it as Appropriate Complementary Feeding Practices. The term of 'core indicator' was used in WHO IYCF Practices Indicators 2008 and not in WHO IYCF Practices Indicators 2021 as the revised version divided into 3 main indicators (Breastfeeding, Complementary Feeding and Other practices indicator) rather than 2 main indicator in 2008 (Core vs Optional indicators)

As ISSSF become one of the three indicator to determine prevalence of ACFP, how the author analyse data as the ISSSF data is meant for the children aged 6-8 months (age group to assess the indicator). Can the author explain on how author assess this indicator? If the denominator was the children age 6-23 months, author need to reanalyse the data.

5. L141-143: Rephrase in the better way to explain the definition of the topic.

6. L239-240: The indicator was not follow the definition of WHO IYCF Practices Indicator 2021 (ISSSF). If the author do not want to follow the indicator's definition, the author need to explain and elaborate more on this topic.

Figure 1: Fig 1 showed the ISSSF indicator data come from the total respondent which is not follow the WHO guideline to asses the IYCF indicators. I assumed the author used the definition as states at line 141-143 and using the WHO IYCF Indicators for assessing infant and young child feeding practices. Standardise in term of definition is important especially to compare the result among the research on this topic.

All the best

Thank you

Reviewer #2: 1. As per the measure in methodology section, appropriate complementary feeding practice is defined as indicator three of the WHO core IYCF i.e. timely introduction of solid, complementary feeding minimum dietary diversity and minimum meal frequency. But in the result section, appropriate complementary feeding practice and all these indicators presented separately. So be clear about the measurement. If you need any correction, correct both in the abstract result section and main findings.

2. Better to specify the "to address associated factors" in conclusion section of abstract.

3. What is basis for classification of monthly income? Better use any standard basis

4. Found missing figure 1 in results section

5. it would be more clear for reader if you include fig. or table related to descriptive findings i.e. timing of introduction of solid, complementary feeding minimum dietary diversity and minimum meal frequency in results section.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Khairul Hasnan Amali

Reviewer #2: Yes: Gayatri Rai

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Mar 6;19(3):e0299969. doi: 10.1371/journal.pone.0299969.r002

Author response to Decision Letter 0

24 Nov 2023

Journal requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

Response: Rechecked

2. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Response: Full ethics statement is included in method section under Ethical Consideration section.

3. We are unable to open your Supporting Information file [Supporting Information.sav]. Please kindly revise as necessary and re-upload.

Response: Supporting Information file is SPSS data file. I have re-uploaded that file. I have also shared that file on figshare https://doi.org/10.6084/m9.figshare.24633153.v1.

4. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: Checked. We have not cited papers that have been retracted.

Review Comments to the Author

Reviewer #1: 1. Line (L) 61-62: WHO recommended to continued breastfeeding up to 2 years of beyond not 12 months as stated. Any comment or justification on author's statement on this matter?

Response: This is the estimated contribution of breastfeeding (Exclusive breastfeeding in the first 6 months of life and continued breastfeeding from 6 to 11 months) and complementary feeding on the prevention of under five deaths.

2. L61-65: The statement is not clear. Please paraphrase the statement to be clearer and what are on basis of this statement?

Response: Paraphrased

3. L88-89: I would suggest the author to consider to follow and standardised the indicator's name according to WHO Unicef IYCF indicator 2021. 'Introduction of solid, semi-solid or soft food 6-8 months (ISSSF)

Response: “Complementary feeding” indicator is replaced with “Introduction of solid, semi-solid or soft food 6-8 months (ISSSF)”

4. L113-119: I would recommend the author to elaborate more on the selection of 3 indicators from 17 IYCF WHO IYCF practice's indicators. To justify why choose the three selected indicators and how classified it as Appropriate Complementary Feeding Practices. The term of 'core indicator' was used in WHO IYCF Practices Indicators 2008 and not in WHO IYCF Practices Indicators 2021 as the revised version divided into 3 main indicators (Breastfeeding, Complementary Feeding and Other practices indicator) rather than 2 main indicator in 2008 (Core vs Optional indicators)

As ISSSF become one of the three indicator to determine prevalence of ACFP, how the author analyse data as the ISSSF data is meant for the children aged 6-8 months (age group to assess the indicator). Can the author explain on how author assess this indicator? If the denominator was the children age 6-23 months, author need to reanalyse the data.

Response: Necessary changes were made.

The research participants of this study were the mothers of children of age 6-23 months. The information regarding ISSSF was collected retrospectively from all the respondent’s whether they initiated introduction of solid, semi-solid or soft food at the age of 6-8 month. The denominator in this indicator contains the information of ISSSF when the age of the children was 6-8 months.

5. L141-143: Rephrase in the better way to explain the definition of the topic.

Response: Previous operation definition is changed to “The proportion of children age 6–23 months who had been introduced to solid, semi-solid, or soft foods at the age between 6 to 8 months.”

6. L239-240: The indicator was not follow the definition of WHO IYCF Practices Indicator 2021 (ISSSF). If the author do not want to follow the indicator's definition, the author need to explain and elaborate more on this topic.

Response: Operation definition of ISSSF is revised to “The proportion of children age 6–23 months who had been introduced to solid, semi-solid, or soft foods at the age between 6 to 8 months”

Figure 1: Fig 1 showed the ISSSF indicator data come from the total respondent which is not follow the WHO guideline to asses the IYCF indicators. I assumed the author used the definition as states at line 141-143 and using the WHO IYCF Indicators for assessing infant and young child feeding practices. Standardise in term of definition is important especially to compare the result among the research on this topic.

Response: Operation definition was changed. Even though, almost all study cited the standard definition of WHO guideline, they have calculated ISSSF by taking total respondents, so we can compare the result with these studies.

Reviewer #2: 1. As per the measure in methodology section, appropriate complementary feeding practice is defined as indicator three of the WHO core IYCF i.e. timely introduction of solid, complementary feeding minimum dietary diversity and minimum meal frequency. But in the result section, appropriate complementary feeding practice and all these indicators presented separately. So be clear about the measurement. If you need any correction, correct both in the abstract result section and main findings.

Response: All three indicators along with Appropriate complementary feeding practice was presented in the figure because those indicator has equal importance in Infant and Young Child Nutrition and will also give readers comprehensive picture from which ACFP is derived.

2. Better to specify the "to address associated factors" in conclusion section of abstract.

Response: Associated factors are presented in result section.

3. What is basis for classification of monthly income? Better use any standard basis

Response: Monthly income was not classified in any standard basis because authentic data related to average monthly income of general population is lacking.

4. Found missing figure 1 in results section

Response: Figure was uploaded separately

5. it would be more clear for reader if you include fig. or table related to descriptive findings i.e. timing of introduction of solid, complementary feeding minimum dietary diversity and minimum meal frequency in results section.

Response: As per the guideline of PLOS ONE, all figures should be uploaded separately. So, figure was uploaded separately.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0299969.s002.docx (19.4KB, docx)

Decision Letter 1

Naveed Sadiq

6 Feb 2024

PONE-D-23-31826R1Appropriate complementary feeding practice and associated factors among mothers of children aged 6-23 months in Bhimphedi rural municipality of NepalPLOS ONE

Dear Dr. K.C.,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The abstract is a bit unclear. Please make necessary changes as per the reviewer comments.

Please submit your revised manuscript by Mar 22 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Naveed Sadiq, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: May i suggest to the author to remove Lines 229-230 as it is repetitive?

And Good luck to the author

Reviewer #2: Authors probably misunderstood the previous round comment 1. I think the study's outcome variable is appropriate complementary feeding practice (ACFP). They have been measured ACFP by using a composite indicator comprising three of the WHO core IYCF indicators i.e. timely introduction of solid, complementary feeding, minimum dietary diversity, and minimum meal frequency. But in abstract results are not so clear therefore, kindly please go through the main finding's result section and write in that way. I accept that the three indicators are equal important but the comment is just for writing style and clarity.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Khairul Hasnan Amali

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Mar 6;19(3):e0299969. doi: 10.1371/journal.pone.0299969.r004

Author response to Decision Letter 1

10 Feb 2024

Reviewer #1: May i suggest to the author to remove Lines 229-230 as it is repetitive?

And Good luck to the author

Response: Removed

Thank you

Reviewer #2: Authors probably misunderstood the previous round comment 1. I think the study's outcome variable is appropriate complementary feeding practice (ACFP). They have been measured ACFP by using a composite indicator comprising three of the WHO core IYCF indicators i.e. timely introduction of solid, complementary feeding, minimum dietary diversity, and minimum meal frequency. But in abstract results are not so clear therefore, kindly please go through the main finding's result section and write in that way. I accept that the three indicators are equal important but the comment is just for writing style and clarity.

Response: Necessary changes have been made in abstract

Attachment

Submitted filename: Response to Reviewers.docx

pone.0299969.s003.docx (15.1KB, docx)

Decision Letter 2

Naveed Sadiq

21 Feb 2024

Appropriate complementary feeding practice and associated factors among mothers of children aged 6-23 months in Bhimphedi rural municipality of Nepal

PONE-D-23-31826R2

Dear Dr. K.C.,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Naveed Sadiq, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Naveed Sadiq

25 Feb 2024

PONE-D-23-31826R2

PLOS ONE

Dear Dr. K.C.,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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PLOS ONE Editorial Office Staff

on behalf of

Dr. Naveed Sadiq

Academic Editor

PLOS ONE

Associated Data

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    Supplementary Materials

    S1 File

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    pone.0299969.s001.sav (31.7KB, sav)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0299969.s002.docx (19.4KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0299969.s003.docx (15.1KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its supporting information files or can be found in https://doi.org/10.6084/m9.figshare.24633153.v1.

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