Assessment of infant and child feeding index and nutritional status among children aged 6–36 months in Kabul, Afghanistan

ABSTRACT

Background:

The Infant and Child Feeding Index (ICFI) is a comprehensive, age-specific measure that evaluates the overall feeding practices of infants and young children. This study aimed to evaluate the feeding practices of children in Kabul, Afghanistan, and explore the relationship of ICFI with the nutritional status of children aged 6–23 months.

Methods:

The World Health Organization (WHO) growth standards were employed to assess undernutrition. Logistic regression analysis was performed to evaluate the association between ICFI and the nutritional status of the children.

Results:

Approximately half of the children (47.3%; n = 182) were boys, while 203 (52.7%) were girls. Colostrum feeding was common among 84% of mothers, while 54% of mothers started breastfeeding after 1 hour of birth. Concerning complementary feeding practices, 21.8% of mothers started before six months, while 17.1% after six months. However, 54% of mothers did not practice exclusive breastfeeding. Most children (67%) had a low ICFI score, with only 3.9% falling into the high ICFI category. Notably, a lower ICFI score was significantly associated with underweight (P < 0.5).

Conclusion:

The present study’s findings revealed that a majority of children had low ICFI scores. ICFI indices and stunting or wasting had no significant association, but there was a significant relationship between the ICFI indices and underweight. Additionally, unhealthy practices were common among mothers. To address this, a comprehensive nutrition program is necessary to promote good feeding and dietary practices, which could help reduce undernutrition among children.

Background

Undernutrition is a leading cause of mortality and is responsible for 45% fatality among children around the globe.[1] In Afghanistan, undernutrition is responsible for about half of all fatalities in children under the age of five, resulting in the loss of approximately 3 million young lives each year.[2] In 2021, 14 million Afghans were noted to be deficient in food supplies, with 95% of households not having enough to eat.[3] In 2022, Afghanistan ranked 109^th out of 121 countries on the Global Hunger Index, indicating a “serious” level of hunger.[4]

According to UNICEF, only half of the babies in Afghanistan receive exclusive breastfeeding in their first six months, and only 12 percent of the nation’s children aged 6–24 months receive the appropriate variety and quantity of food for their age.[5] The “critical window period” is essential for the infants and young children and spans from birth to two years of age, a time when the brain undergoes rapid growth and development. Nutrition experts coined this term due to the significant developmental changes that occur during this phase. However, this period is also prone to various health issues, including micronutrient deficiencies, growth faltering, and illnesses like pneumonia and diarrhea.[6] Infant and young child feeding (IYCF) is one of the greatest nutritional interventions that can support the child during this critical period.[7] IYCF practices have an influence on the nutritional status of young children. The age range of 6 to 36 months is a critical period during which poor feeding practices can lead to undernutrition, resulting in poor school performance, delayed cognitive development, and decreased productivity later in life.[8] According to the World Health Organization, IYCF provides a set of recommendations for the appropriate feeding of infants and young children.[9] It comprises breastfeeding, exclusive breastfeeding, and complementary feeding. Therefore, the availability of a valid, reliable, and simple indicator using IYCF practices is critical for evaluating feeding conditions and tracking the progress of programs aimed at improving nutritional status.[10]

Ruel and Menon developed the ICFI tool, which was later refined by in 2002 using Demographic and Health Survey data from Ethiopia.[11] This ICFI tool was used in modified form in several countries. As a composite index, the ICFI can comprehensively measure IYCF practices.[12,13]

It is very necessary to measure feeding practices among children in Afghanistan, especially after the regime change (i.e., Taliban), where people are struggling to end hunger. To our best knowledge, there are very limited studies regarding infant feeding practices, and also, the use of this composite index (i.e., ICFI). To fulfill this research gap, the current study was conducted to evaluate ICFI scores and also to find the relationship between nutritional status and the ICFI among young children aged 6–36 months. This tool is not only beneficial for practitioners but also for the caregivers. Practitioners will be able to use this evidence-based tool to assess, identify, and monitor infants and toddlers at risk of malnutrition in relation to their feeding practices, and to design immediate interventions in low-resource settings in Afghanistan. For caregivers, it will support early identification of inadequate practices and provide timely counselling, thereby reducing malnutrition.

Methods

Study setting and study design

A descriptive cross-sectional study following STROBE criteria was carried out at a tertiary hospital, Ataturk Children’s Hospital, Kabul, Afghanistan. This study was conducted from September to December 2022. Children aged 6–36 months of age that visited the hospital and their parents gave consent were included in the study, while severely sick patients having sepsis, high fever, or any other complex conditions where children were unable to give anthropometric data were excluded from the study. The sample size was calculated according to the formula (Sample size = (1.962) * (0.5) * (1-0.5)/(0.05) 2 = 384.16). Out of the respondents reached, 405 young children were screened, with 20 children excluded from the analysis due to missing information. In the final analysis, 385 respondents were included.

Variables included in the study

Variables included were age (groups), gender (boys and girls), father and mother education (illiterate, nonformal, primary, secondary, higher), family size, family type, birth interval, height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) Z-scores, breastfeeding initiation, feeding of colostrum, breastfeeding frequency, exclusive breastfeeding, starting of complementary feeding, ICFI scores, bottle feeding information, dietary diversity, food group frequency, hygiene, and sanitation information.

Anthropometric Measurement

The height/length of children aged 6–24 months was measured using a length board to the nearest 0.5 cm, while the height of children aged 24–36 months was measured using a stadiometer. Digital scales were used to measure weight to the nearest 0.1 kg. The equipment used for these anthropometric measurements was standardized, and data were recorded in duplicate.

Infant and child feeding score

A previous version that validated ICFI score questionnaire was used.[14,15] During the interview with mothers of the children, information with respect to feeding practices was obtained. The questionnaire included information regarding breastfeeding, bottle feeding, dietary diversity, and questionnaire of seven-day food group frequency. Breastfeeding was given positive scoring, while bottle feeding was given zero scores. With respect to dietary diversity, seven food groups are considered to assess intake of dietary: 1) products related to dairy, 2) foods which are rich in carbohydrate, 3) fish and meat, 4) egg, 5) vegetable protein, 6) fruits and vegetables which are rich in vitamin A, and 7) other fruits/vegetables. Caretakers were asked with regard to eating of food groups taken by the child. The variable “Food Group Frequency”: includes following food groups: 1. grains/roots/tubers (known as staple), 2. nuts/legumes, 3. diary (other than breast milk), 4. flesh foods, 5. Eggs, 6. fruits and vegetables that are rich in vitamin A, 7. other fruits and vegetables. Each food group received a score of zero if it was not consumed in the past seven days, a score of one if consumed for one to three days, and a score of two if consumed for four or more days. The cumulative score was ranging from zero to fourteen. Upon constructing this intermediate variable, distributions are examined within age groups. The child’s dietary diversity reveals which food groups the child has consumed. The value was different in various age groups. The value of complementary feeding also differs in various age groups. Finally, the scores of all five components were summed (range: 0–9). The scores were divided into three categories: 1. Low (0 to 5), 2. Medium (6 to 7), and 3. High (8 to 9) [Supplementary Table 1].

Supplementary Table 1.

Components of Infant and Child Feeding Index and scoring

ICFI Components	Age of children
	6-8 months	9-11 months	12-36 months
Breast feeding	Yes=2	Yes=2	Yes=1
	No=0	No=1	No=0
Bottle feeding	Yes=0	Yes=0	Yes=0
	No=1	No=1	No=1
Dietary diversity (past 24 H)	0-1 food group=0	0-2 food groups=0	0-2 food groups=0
	2 food groups=1	3 food groups=1	3 food groups=1
	3 or more food groups=2	4 or more food groups=2	4 or more food groups=2
Frequency of food group score٭(past 7 days)	0-2=0	0-3=0	0-3=0
	3-4=1	4=1	4-5=1
	5 or more=2	5 or more=2	6 or more=2
Frequency of feeding solids and semi-solids	0 or 1 time=0	0-2 times=0	0-2 times=0
	2 times=1	3 times=1	3 times=1
	3 or more times=2	4 or more time=2	4 times=2
			5 or more times=3

Source: (Palanichamy and Solanki, 2021)[1]

Statistical analysis

Anthro 2006 software (developed by WHO) was used to determine HAZ, WAZ, and WHZ. Z-scores less than -2 were considered indicative of stunting, wasting, and underweight.[16] Further data analysis was conducted using SPSS version 26.0. Descriptive statistics, such as frequency and percentages, were used. To find an association between nutritional status and ICFI score, logistic regression was used. A P value less than 0.05 was considered significant.

Results

Socioeconomic and demographic characteristics of the study population

In this study, 385 children were included and their respective care takers were interviewed. Sociodemographic information of the respondents is shown in Table 1. There were 47.3% boys and 52.7% girls. Nearly two-thirds (65.5%) of the children were aged 12–36 months, while 19.2% and 15.3% (n = 59) belonged to the 6–8 months and 9–11 months age groups, respectively. Among mothers of the respondents, 49.1% were uneducated, 3.9% got nonformal education; 26.2% of them got primary education; 13.2% got secondary education; and 7.5% got higher education. In terms of the education of fathers, 49.1% (n = 189) were illiterate, 13 (3.4%) have got nonformal education; 97 (25.2%) were educated primarily; 77 (20%) passed the secondary; and 29 (7.5%) of the fathers had earned university degree. Among the respondents, 187 (48.6%) belonged to a combined/joint family, and 198 (51.4%) belonged to a nuclear family. About four-fifth of the children (78.2%) belonged to grater family size which was >5 members. Close to one-fifths (21.8%) belonged to the family of <5 members. Of these, 109 (28.3%) had a birth spacing of more than two years, while 178 (46.2%) had a birth space less than two years. About one-fourths (25.5%) of the children were born firstly. Moreover, 84.2% received colostrum, 54% were breastfed after 1 hour of birth, 21.8% started complementary food less than six months from while 17.1% started after six months, 53.2% were exclusively breastfed. Also less than half of them (40.8%) received less than eight times per day, while 131 (34%) of them were breastfeed more than eight times per day. Great majority of the children had access to toilet (98.7%, n = 380). The data revealed alarming gaps in access to essential services, including access to latrine (1.3% lacking), safe water (22.1% lacking), and handwashing facilities with soap (44.7% lacking).

Table 1.

Socioeconomic and sociodemographic characteristics of the children

Characteristics	n (%)
Gender
Boys	182 (47.3)
Girls	203 (52.7)
Age group (month)
6–8	74 (19.2)
9–11	59 (15.3)
12–36	252 (65.5)
Maternal education
Informal	15 (3.9)
Primary level	101 (26.2)
Secondary level	51 (13.2)
Higher level	29 (7.5)
Illiterate	189 (49.1)
Paternal education
Informal	13 (3.4)
Primary level	97 (25.2)
Secondary level	77 (20.0)
Higher level	76 (19.7)
Illiterate	122 (31.7)
Family type
Nuclear	198 (51.4)
Joint	187 (48.6)
Family size (number)
1–5	84 (21.8)
More than 5	301 (78.2)
Birth interval (years)
>2	109 (28.3)
<2 years	178 (46.2)
First birth	98 (25.5)
Colostrum Intake
Yes	324 (84.2)
No	61 (15.8)
Breastfeeding initiation
Within first hour	177 (46.0)
.>1 hour	208 (54.0)
Complementary feeding Initiation (months)
<6	84 (21.8)
6	235 (61.1)
>6	66 (17.1)
Exclusive breastfeeding
Yes	180 (46.8)
No	205 (53.2)
Breastfeeding frequency (day)
<8	157 (40.8)
>8	131 (34.0)
Availability of toilet facility
Yes	380 (98.7)
No	5 (1.3)
Availability of safe water
Yes	300 (77.9)
No	85 (22.1)
Availability of hand washing facility with soap
Yes	213 (55.3)
No	172 (44.7)

Nutritional status of the children

In this study, 38.7% had stunting-based undernutrition. Stunting was more prevalent among 56% of male children. Among children aged 6–8 years, 33.7% were stunted, similar to the percentage in the 9–11 age group (33.8%). In the 12–36 age group, 41.2% of the children were stunted. Regarding underweight, 30.6% were classified as underweight. The prevalence of underweight-based undernutrition was highest among children aged 6–8 years (40.5%). In the 9–11 age group, the percentage was 20.3%, and in the 12–36 age group, it was 30.1%.

The prevalence of wasting was 11.9%. The majority of wasted children were in the 12–36 age group (11.9%), while 16.2% were aged 6–8 years. A smaller proportion (6.7%) of children in the 9–11 age group were wasted.

Association between IYCF and nutritional status

Table 2 displays the relationship between IYCF and nutritional status. There was a significant association between breastfeeding and stunting. Breastfed children were less likely to be stunted (P value = 0.033). Children in the low complementary feeding frequency group had a higher likelihood of being stunted compared to those in the medium and high frequency groups (P value = 0.012). There was no significant association between feeding practices and underweight. Regarding wasting, bottle-fed children were more wasted than non-bottle-fed children, with a significant difference (P value = 0.001). Additionally, there was a significant relationship between a medium category of dietary diversity and wasting. This suggests that children who consumed three food groups in the past 24 hours (or two food groups for those aged 6–9 months) had a higher likelihood of being wasted compared to those in the high category, who consumed ≥ four food groups (or ≥ three food groups for children aged 6–9 months) (P value = 0.027).

Table 2.

Association of infant and young child feeding practices with nutritional status

IYCF practices	Nutritional indicators (n=385)
	WHZ Frequency (n)		WAZ Frequency (n)		HAZ Frequency (n)
	Normal	Wasted	Normal	Underweight	Normal	Stunted
Breastfeeding
Yes	241	28	194	75	172	97
No	99	17	79	37	65	51
P	0.682		0.369		0.031
Bottle feeding
Yes	98	26	83	41	75	49
No	242	19	190	71	162	99
P	0.001		0.299		0.962
Dietary diversity score
Low	94	10	73	31	62	42
Medium	119	24	98	45	86	57
High	127	11	102	36	89	49
P	0.027		0.706		0.795
Food group frequency score
Low	138	16	106	48	88	66
Medium	119	20	98	41	85	54
High	83	9	69	23	64	28
P	0.493		0.688		0.240
Complementary feeding frequency score
Low	95	13	72	36	57	51
Medium	171	18	139	50	121	68
High	74	14	62	26	59	29
P	0.481		0.456		0.046

IYCF=Infant and young child feeding, WHZ =weight-for-height, WAZ=weight-for-age, HAZ=height-for-age

Association of ICFI indices with nutritional status

Table 3 depicts the association between ICFI indices and nutritional status. ICFI scores were not significantly associated with stunting and wasting. There was a significant association between underweight and ICFI scores. In the logistic model, children with low (OR = 0.331; CI = 0.114–0.961, P < 0.05) and medium ICFI category (OR = 0.174; CI = 0.056–0.540, P < 0.05) had higher odds of being underweight.

Table 3.

Relationship between of ICFI indices and nutritional status

ICFI score categories	WHZ		WAZ		HAZ		P	OR (CI)
	Normal	Wasted	Normal	Underweight	Normal	Stunted
Low (0–5)	227 (58.9%)	32 (8.3%)	173 (44.9%)	86 (22.3%)	153 (39.7%)	106 (27.5%)	WHZ: 0.123 WAZ: 0.042 HAZ: 0.661	WHZ: 0.388 (0.116–1.291) WAZ: 0.331 (0.114–0.961) HAZ: 0.792 (0.279–2.250)
Moderate (6–7)	101 (26.2%)	10 (2.5%)	88 (22.8%)	23 (5.9%)	75 (19.4%)	36 (9.3%)	WHZ: 0.053 WAZ: 0.002 HAZ: 0.280	WHZ: 0.272 (0.073–1.015) WAZ: 0.174 (0.056–0.540) HAZ: 0.549 (0.185–1.631
High (8–9)	11 (2.8%)	4 (1%)	6 (1.5%)	9 (2.3%)	8 (2%)	7 (1.8%)	Ref	Ref

ICFI=Infant and Child Feeding Index, WHZ=weight-for-height, WAZ=weight-for-age, HAZ=height-for-age

Discussion

Proper IYCF practices are crucial for preventing stunting during infancy and early childhood, as well as breaking the intergenerational cycle of undernutrition.[17] IYCF is a beneficial public health approach with multiple arms to prevent mortality and morbidity in children.[18] Although IYCF is a multidimensional issue, achieving successful outcomes, particularly regarding complementary feeding practices, remains challenging worldwide, with even more adverse outcomes in developing countries. Afghanistan holds one of the highest rates of stunting among under-5 children. In 2021, Global Hunger Index ranked the nation at 103^th among 116 countries. The latest data show that 13000 newborn babies died in Afghanistan since January 2022 on account of malnutrition and other diseases.[3] These facts and figures are an indication of high level of hunger and widespread prevalence of malnutrition in the country. However, accuracy of IYCF has been an issue since long ago so long as it has a multidimensional nature. Indicators for measuring optimal breastfeeding have been available for some time; however, only limited work has been undertaken to develop and validate a comprehensive index assessing IYCF practices holistically[18] for predicting and improving children’s nutritional status. The IYCF index, developed by Ruel and Menon, evaluates infant and young child feeding practices both as a single comprehensive index and in a compound manner.[19] A study from India confirmed that the ICFI index is a useful tool for collecting information on various aspects of young child feeding practices.[15] It can be applied in public health policies and strategies to address complementary feeding challenges comprehensively and to track changes in feeding practices.[15] Our study contributes to this ongoing validation effort by applying the ICFI in the complex and under-researched context of Afghanistan.

This study measured IYCF practices using the ICFI as a single index and evaluated its relationship with nutritional status. Ruel and Menon’s assessment of the ICFI, demonstrated a correlation between children’s feeding practices and HAZ, particularly after the age of 12 months.[20] Among children ages less than a year, the association was weak but gradually strengthened as they grew older. Regression analysis indicated that adequate feeding practices were necessary for children from lower socioeconomic groups than for those from higher socioeconomic groups. An Ethiopian study observed a similar relationship among rural children as when they applied the ICFI approach to a different population.[11] They also assessed the association of every single component of ICFI with nutritional status of children, especially HAZ of the children. Interestingly, healthy practices, such as breast-feeding and no-bottle-feeding, were linked to poorer HAZ of children. This negative relationship may be due to differing socioeconomic statuses (a confounding factor); wealthier and mothers with higher education are more inclined to use bottle-feeding than their less affluent counterparts. Our findings, however, diverge significantly in this regard. We found a clear protective effect of breastfeeding against stunting and a strong detrimental effect of bottle feeding on wasting, suggesting that in Kabul’s specific socioeconomic landscape, these practices retain their expected biological effects, un-masked by the wealth confounders seen in other settings.[21,22]

A previous study used a modified ICFI tool, which demonstrated a significant association between ICFI and HAZ of children aged 6–36 months.[23] In contrast, the current study found no association between ICFI scores and stunting. This discrepancy could be attributed to the chronic nature of stunting, which is influenced by a cascade of factors beyond current feeding practices, including maternal nutrition, recurrent infections, and environmental enteric dysfunction.[24]

Lohia and colleagues by doing a research in Mumbai, India, also discovered that there is no significant relationship between ICFI score and stunting.[25] A study carried out in urban Vadodara indicated that there was no significant link between the Infant and Child Feeding Index (ICFI) score and stunting.[26] Another study conducted in an urban tertiary care institute also showed that there is no significant association between ICFI and not only stunting but also other nutritional indicators. The convergence of our null finding with these studies from South Asia strengthens the hypothesis that the ICFI may be a less sensitive predictor for chronic coexisting forms of undernutrition (stunting) in certain urban environments, potentially due to the overwhelming influence of poverty and poor sanitation.[27]

The most robust finding of our analysis was the significant association between ICFI and underweight. Logistic regression confirmed that children with low and medium ICFI categories had higher odds of underweight. This finding is supported by a study done in the urban slum of Ahmadabad, India. The study reports that children with a higher ICFI score possess higher weight-for-age Z score.[9] There was a significant positive relationship between ICFI scores and eight-for-age Z-score in a Maldivian’s study.[28] This consistent association across studies indicates that the ICFI is a more reliable indicator of acute undernutrition (underweight), which is more directly impacted by current dietary intake and energy deficiency.[29]

Also, children of 6–8 age group had lower chance of falling into low ICFI category (AOR = 0.089; CI = 0.013–0.615) as well as medium ICFI category (AOR = 0.123; CI = 0.017–0.861). This may be because children in this age group require less complementary food compared to other age groups, especially considering that the primary issues of child undernutrition in Afghanistan stem from food insecurity and poverty. Shifting to individual ICFI components, there was a significant association between breastfeeding and stunting. Breast fed children were less likely to be stunted (P value = 0.033). A similar study found that breastfeeding plays a protective role against stunting.[30] However, children with low category of complementary feeding frequency were more likely to be stunted relative to those who belonged to medium and high categories. A research carried out by Sefrina Rukmawati showed the same result.[31] In the context of wasting, bottle-fed children were more wasted than non-bottle-fed children; the difference was significant (P value = 0.001). A study conducted in Maharashtra, India, also found that bottle feeding in babies leads to wasting.[32] The coherence of these individual component analyses with global evidence bolsters the internal validity of our findings, even as the composite ICFI index showed a more selective association.[33]

There were certain limitations in this study. First, as a cross-sectional study, it only shows a causal effect. Data regarding dietary practices were collected from caregivers, which may involve recall bias. Additionally, there was some cultural sensitivity in collecting data from respondents due to the Taliban regime. This study is conducted in one center which may not be generalizable to other parts. However, this might be the first comprehensive study to evaluate ICFI and undernutrition.

Conclusion

This study highlighted that the majority of children had low ICFI scores. There was no association found between the ICFI indices and stunting or wasting; however, a significant association was observed between the ICFI indices and underweight. Breastfeeding significantly lowered the chance of stunting among children, as did sufficient complementary feeding. Conversely, bottle feeding was a risk factor for wasting among children. The majority of respondents had poor feeding practices. To address this issue, a comprehensive nutrition program is essential to promote healthy feeding and dietary practices, which could contribute to reducing undernutrition among children. A comprehensive nutrition program should include nutrition knowledge sessions for both staff and mothers, which could enhance their understanding of feeding practices for infants and young children in Afghanistan. In the future, ICFI needs to be generalized for the whole country through longitudinal research-based assessment.

Data availability statement

All the data are included in this manuscript.

Ethical standards disclosure

This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and the ethical committee of Ataturk Children’s Hospital, Kabul, Afghanistan (S.N/10/15) and the ethical committee of The University of Haripur, Pakistan, approved this study (UOH/DASR/2022/1142). Written informed consent was obtained from the caregiver of all subjects.

Authors contribution

Ijaz ul Haq, Cui Hou, and Mohammad Taqi Rezaee conceptualized and wrote the original article. Shahbaz Ahmad Zakki, Amir Muhammad, and Sania Ashfaq made contribution in the editing, visualization, and formal analysis. Mohammad Taqi Rezaee, Sania Meraj, and Muhammad Imtiaz made contribution in the methods and investigations. Arigong Gaowa and Hu Xiaojing reviewed the article.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This project was funded by the Research Project conducted at the Inner Mongolia Maternal and Child Health Care Hospital (Project No. 2024FYYNC053); the Special Project on Science and Technology Revitalization of Inner Mongolia at Shanghai Jiao Tong University Inner Mongolia Institute (2023XYJGO001-01-09); the CAMS Innovation Fund for Medical Sciences (2019-I2M-5-002); the National Key Research and Development Project of China (2021YFC270100, 2016YFC1000500).