Abstract
The complementary feeding period is an important time for children's growth and development. This study was conducted to 1) determine the feeding behaviors of 6- to 36-month-old children in Myanmar, 2) explore health effects of feeding behaviors, and 3) determine factors associated with feeding behaviors. A total of 807 children and their mothers (N = 642) were recruited from nine villages in Kachin, Shan, and Kokang, Myanmar. Feeding behaviors and sociodemographic characteristics were investigated using a validated questionnaire. Hemoglobin and anthropometric indicators were measured during the fieldwork. In our sample, 18.6%, 72.7%, and 9.8% of children were introduced to complementary foods (CFs) earlier than 4 months of age, between 4 and 8 months of age, and later than 8 months of age, respectively. For different types of CFs, up to the age of 24.1–36 months, there were still 6.5% and 4.1% of the children who had never been introduced to eggs and meat. Introduction of CFs earlier than 4 months of age was a risk factor for being underweight (age-adjusted odds ratio (ORadjust-age) = 1.7, 95% confidence interval (CI) = 1.2–2.5) and for stunting (ORadjust-age = 1.6, 95% CI = 1.1–2.3), whereas introduction of CFs later than 8 months of age was a risk factor for anemia (ORadjust-age = 3.5, 95% CI = 1.7–7.2). Mothers who had anemia (OR = 3.7, 95% CI = 2.0–6.9) tended toward early introduction of CFs. Women with a lower family income tended toward later introduction of CFs (OR = 2.0, 95% CI = 1.3–3.3). This study demonstrated that inappropriate feeding behavior was one of the important causes of malnutrition.
Introduction
Myanmar (Burma) is undergoing a complex political and economic transformation, from an area facing a long civil war and military regimen to one in the process of peace and democratization.1 In Myanmar, over 70% of the population resides in rural areas, and over 60% of the population is composed of women and children.2 Even though since 2011, the Myanmar Ministry of Health has been attempting to rehabilitate the fragile health system, setting the goal of achieving universal health coverage by 2030,3 Myanmar's life expectancy at birth of 66.8 years and infant mortality of 62.0 years are still the worst in southeast Asia.1
In this study, nine villages in mountainous peripheral areas of the Kachin, Shan, and Kokang self-administered zones in Myanmar were investigated. All of the villages are located in the northeastern part of Myanmar and border China. According to The Lancet report in 2015, persistent inequalities exist in health outcomes in Kachin, and the infant mortality rate is 94.2 per 1,000 births, and under-five mortality is 149.1 per 1,000 births near the eastern border of Myanmar.4 All of the studied areas suffer from remoteness, civil conflicts, and low socioeconomic development.5 Based on our previous work, chronic childhood malnutrition remains one of the most intractable public health problems in these areas, and the effects of humanitarian aid for enhancing the nutritional status of children are limited because of the complicated causes of malnutrition.6,7 In addition, because of internal conflict, humanitarian aid, such as providing nutritional punch and relief food, is hard to continue for long periods. Some receptive and sustainable interventions urgently need to be explored and implemented.
Adequate nutrition during infancy and early childhood is essential to ensure the growth, health, and development of children to their full potential. For children in developing countries, the World Health Organization (WHO) and United Nations Children's Emergency Fund (UNICEF) recommend exclusive breast-feeding for 6 months and introducing complementary foods (CFs) at 6 months of age with continued breast-feeding until at least 2 years of age.8 Previous study reported that being either too early or delayed in introducing CFs may be associated with adverse consequences. Infants develop more respiratory illnesses and eczema if complementary feeding (CF) is started earlier than 6 months of age, and early CF might expose infants to pathogenic microbes contained in unhygienic food or water.9–11 Conversely, delays in introducing CFs may lead to inadequate nutrient intake, as well as delays in developing eating behaviors and oral–motor skills.12 In addition, the importance of continued breast-feeding for preventing vitamin A deficiency between 12 and 36 months of age has been well documented in developing countries.13 Inappropriate feeding behaviors at this time, in combination with other causes such as infection and food shortage, may be responsible for one-third of malnutrition cases, depending on population, place, time, and season.14 It is worth noting that globally, optimal breast-feeding could prevent 13% of deaths of children aged less than 5 years, whereas appropriate CF practices might result in an additional 6% reduction in under-five mortality.15
In Myanmar, children in the CF period are in one of the most vulnerable groups when breast milk alone is no longer sufficient to meet their nutritional requirements, and their feeding behaviors at this time are still unknown. This study intends to 1) investigate the feeding behaviors of children in the studied areas, 2) explore whether feeding behaviors might affect children's health, and 3) determine factors that might be associated with feeding behaviors.
Methods
Subjects.
This cross-sectional study was conducted in Myanmar from July 2014 to January 2015. Three areas in Myanmar (Kachin, Shan, and Kokang self-administered zones) were selected using a purposive sampling method. Four, three, and two villages in mountainous peripheral areas of Kachin, Shan, and Kokang, respectively, were selected using convenience sampling. A cluster sampling method was used for household selection, and 652 households were screened as having at least one child aged 6–36 months. The children were included with the following criteria: aged 6–36 months without acquired immune deficiency syndrome or human immunodeficiency virus infection and without physical disability. Finally, 642 (98.5%) of the screened households with 807 children (including 138 pairs of siblings, Kachin [N = 382], Shan [N = 285], and Kokang [N = 140]) and their 642 mothers were recruited and volunteered to participate in this study.
Data collection.
The fieldwork was carried out by local health professionals and staff from Health Poverty Action (HPA; a nongovernmental organization founded in 1984 in Britain that works to strengthen poor and marginalized people in their struggle for health) with the support of local health officers.
Trained interviewers collected data on sociodemographic factors, feeding behaviors (including the time of introducing CF and duration of breast-feeding), and self-reported children's illness during the recent 3 months were collected from mothers using an interviewer-administered questionnaire. A food intake frequency questionnaire was used to explore food diversity. Training of the interviewers and an initial site survey were completed before data collection. The preliminary questionnaire testing was completed in a previous study.7
Anthropometric measurements [height, weight, head circumference (HC), and mid-upper arm circumference (MUAC)] were collected during the fieldwork. The Infant/Child Shorrboard (Electronic baby scale, RSP-2060B; Xianyang Huachao Co. Ltd., Shanxi, China) was used to measure child stature, recumbent infant length (if the child was < 85 cm), and weight (with infants/children's clothing and shoes removed). Weight for older children was measured using a portable scale. MUAC was measured at the middle of the left arm using single-slotted insertion tapes (LeCheng 10–100 cm; Zhejiang LeCheng Co. Ltd., Zhejiang, China). HC was measured using a tape. The growth and development status of children was evaluated with weight-for-age ratio Z score (WAZ), height-for-age ratio Z score (HAZ), weight-for-height ratio Z score (WHZ), MUAC Z-score, and HC Z score, which were calculated using the WHO Anthro software (Geneva, Switzerland), where WAZ < −2, HAZ < −2, and WHZ < −2 are defined as underweight, stunting, and wasting, respectively.16 HC Z scores < −2 are defined as small HC. MUAC Z scores < −2 are also defined as wasting.
Blood samples were obtained from finger pricks of both women and children. Hemoglobin (Hb) was tested using HemoCue during fieldwork (HemoCue Hb 201+ analyzer; HemoCue AB, Angelholm, Sweden). According to the age-based Hb criteria designated by the WHO, Hb < 110 mg/L is defined as anemia in both women and children aged 6–36 months.17
Ethics.
The study was conducted in compliance with the Declaration of Helsinki and the local government approved it. The interviewers informed all participants of the procedures and purpose of the study. Whether the screened women and their children were willing to participate in this study would not influence humanitarian decisions. Written consent was obtained from the mothers of all participants before data collection.
Statistical analyses.
IBM SPSS (Predictive analytics software and solutions) Software version 20.0 (IBM Corporation, New York, NY) was used to carry out the analyses. Data were presented as mean ± standard deviation or percentage. To compare health indicators among children with different feeding behaviors, χ2 analyses and ANOVAs were used. A multinomial logistic regression was used to obtain both the crude and age-adjusted odds ratios (ORcrude and ORadjust-age) and 95% confidence intervals (95% CIs) for estimating the association of feeding behaviors with health indicators in children. The data of 642 mothers were used to explore the potential factors associated with maternal feeding behavior. A multinomial logistic regression was performed to estimate the associations between time of CFs introduction and the associated factors. In the multivariate analysis, only factors that were found to be associated with time of CF introduction in a single analysis were entered into the regression model (only the factors with P < 0.05 were used to develop the regression model). A P value < 0.05 was considered different at a statistically significant level.
Results
Characteristics of participants.
A total of 807 children and mothers were qualified and recruited for this study. The majority ethnic group of the children was Burman (65.2%), followed by Shan (24.2%), Kokang (9.9%), and De'ang (0.7%). Of the child participants, 52.9% were boys and 47.1% were girls. The mean age of the children was 20.6 ± 9.7 months, with 63.7% of the children between the ages of 6 and 24 months and 36.3% were between the ages 24.1 and 36 months. There were 31 (6.3%) children who received humanitarian aid (nutritional punch or humanitarian food) in the past 3 months.
Feeding behaviors.
There were 145 (18.6%), 583 (72.7%), and 79 (9.8%) children who were introduced to CFs earlier than 4 months of age, between 4 and 8 months of age, and later than 8 months of age, respectively. A total of 32.0% of the children introduced to CFs were older than 6 months. The average age of CFs introduction was 5.8 ± 2.8 months. Considering different types of CFs, 91.1%, 45.1%, and 49.6% of the children aged 6–12 months had already been introduced to grain, egg, and meat, respectively. Of children between 12.1 and 24 months of age, 100%, 86.2%, and 95.2% had already been introduced to grain, egg, and meat, respectively. In children aged 24.1–36 months, 6.5% and 4.1% still had never been introduced to egg and meat, respectively. For duration of breast-feeding in children aged 18–36 months, 66 (14.6%) were breast-fed less than 6 months, 100 (22.1%) were breast-fed between 6 and 17.9 months, and 287 (63.4%) were breast-fed longer than 18 months. There were no gender or ethnic differences among children having different ages at CFs introduction (gender: χ2 = 3.947, P = 0.139; ethnic: χ2 = 9.358, P = 0.154) and with different durations of breast-feeding (gender: χ2 = 2.544, P = 0.280; ethnic: χ2 = 9.342, P = 0.155). Receiving humanitarian aid in the past 3 months was not associated with time of CFs introduction (χ2 = 1.811, P = 0.404) and duration of breast-feeding (χ2 = 0.886, P = 0.642).
Health indicators of children with different feeding behaviors.
Approximately 13.1%, 55.3%, and 39.7% of the studied children were found to suffer from wasting (WAZ < −2 Z score), stunting, and being underweight, respectively. A total of 6.6% of children were wasting according to the MUAC < −2 Z score, and 13.2% of the children had a small HC. Introduction of CFs earlier than 4 months of age was a risk factor for being underweight and stunting. The prevalence of wasting (WAZ < −2 Z score), MUAC < −2 Z score, and small HC demonstrated no significant differences among children with different ages of CFs introduction (Table 1). Only data of children who were older than 18 months were used for analyzing the health effects of breast-feeding duration (N = 453). All growth and development indicators showed no significant differences among children with different breast-feeding durations (Table 1).
Table 1.
Comparison of prevalence of wasting, stunting, underweight, and small HC among children with different time of introduction of CFs and different duration of breast-feeding (N, %)
| Time of introduction of CFs | Duration of breast-feeding* | ||||||
|---|---|---|---|---|---|---|---|
| < 4 months | 4–8 months | > 8 months | < 12 months | 12–17.9 months | ≥ 18 months | ||
| Wasting | No | 125 (87.4) | 498 (86.8) | 67 (84.8) | 58 (89.2) | 84 (84.8) | 242 (85.5) |
| Yes | 18 (12.6) | 76 (13.2) | 12 (15.2) | 7 (10.8) | 15 (15.2) | 41 (14.5) | |
| ORcrude (95% CI) | 0.9 (0.5, 1.6) | Ref. | 1.2 (0.6, 2.3) | 0.8 (0.1, 6.4) | 0.7 (0.2, 1.9) | Ref. | |
| ORadjust-age (95% CI) | 1.0 (0.6, 1.7) | Ref. | 1.1 (0.6, 2.2) | 0.8 (0.1, 6.3) | 0.7 (0.2, 2.0) | Ref. | |
| MUAC < −2 z | No | 132 (91.7) | 546 (93.8) | 74 (93.7) | 64 (98.5) | 91 (91.0) | 269 (94.1) |
| Yes | 12 (8.3) | 36 (6.2) | 5 (6.3) | 1 (1.5) | 9 (9.0) | 17 (5.9) | |
| OR (95% CI) | 1.4 (0.7, 2.7) | Ref. | 1.0 (0.4, 2.7) | – | 2.1 (0.8, 5.1) | Ref. | |
| ORadjust-age (95% CI) | 1.4 (0.7, 2.7) | Ref. | 1.0 (0.4, 2.7) | – | 1.9 (0.7, 5.1) | Ref. | |
| Stunting | No | 54 (37.2) | 277 (47.5) | 30 (38.0) | 30 (45.5) | 43 (43.0) | 124 (43.2) |
| Yes | 91 (62.8) | 306 (52.5) | 49 (62.0) | 36 (54.5) | 57 (57.0) | 163 (56.8) | |
| OR (95% CI) | 1.5 (1.1, 2.2)† | Ref. | 1.5 (0.9, 2.4) | 1.0 (0.3, 3.8) | 0.8 (0.5, 1.5) | Ref. | |
| ORadjust-age (95% CI) | 1.6 (1.1, 2.3)† | Ref. | 1.4 (0.9, 2.3) | 1.0 (0.3, 3.8) | 0.9 (0.5, 1.6) | Ref. | |
| Underweight | No | 72 (50.0) | 367 (63.0) | 47 (59.5) | 33 (50.0) | 64 (64.0) | 170 (59.2) |
| Yes | 72 (50.0) | 216 (37.0) | 32 (40.5) | 33 (50.0) | 36 (36.0) | 117 (40.8) | |
| OR (95% CI) | 1.7 (1.2, 2.5)† | Ref. | 1.2 (0.7, 1.9) | 3.1 (0.8, 12.5) | 1.2 (0.7, 2.2) | Ref. | |
| ORadjust-age (95% CI) | 1.7 (1.2, 2.5)† | Ref. | 1.1 (0.7, 1.8) | 3.1 (0.8, 12.5) | 1.3 (0.7, 2.4) | Ref. | |
| HC < −2 z score | No | 127 (88.2) | 495 (86.4) | 69 (87.3) | 59 (92.2) | 80 (82.5) | 245 (86.0) |
| Yes | 17 (11.8) | 78 (13.6) | 10 (12.7) | 5 (7.8) | 17 (17.5) | 40 (14.0) | |
| OR (95% CI) | 0.9 (0.5, 1.5) | Ref. | 0.9 (0.5, 1.9) | 1.8 (0.4, 8.8) | 0.6 (0.2, 1.7) | Ref. | |
| ORadjust-age (95% CI) | 0.9 (0.5, 1.5) | Ref. | 0.9 (0.5, 1.9) | 1.8 (0.4, 8.8) | 0.6 (0.2, 1.8) | Ref. | |
CFs = complementary foods; CI = confidence interval; HC = head circumference; MUAC = mid-upper arm circumference; ORadjust-age = age-adjusted odds ratio; ORcrude = crude odds ratio; Ref. = reference.
Only children older than 18 months were used for analysis (N = 453).
P < 0.05.
High anemia prevalence (73.4%) was found in this study, with 70.0% in the 6–24 months group and 75.4% in the 24.1–36 months group. Introduction of CFs later than 8 months of age was a risk factor for anemia (ORcrude = 3.2, 95% CI = 1.6–6.6; ORadjust-age = 3.5, 95% CI = 1.7–7.2). The Hb level in children who had been introduced to CFs earlier than 4 months of age, within 4–8 months of age, and later than 8 months of age was 93.4 ± 20.7, 91.1 , and 84.2 ± 18.7 g/L, respectively (F = 3.849, P = 0.022). The Hb levels were similar among children with different durations of breast-feeding (F = 0.841, P = 0.432).
According to the mothers' reports, 67.5% and 74.5% of the children experienced diarrhea and fever, respectively, over the past 3 months. Both early and later introduction of CFs increased the prevalence of fever, and early introduction of CFs also increased the risk of diarrhea (Table 2). There were no significant differences in the prevalence of diarrhea and fever among children with different durations of breast-feeding (Table 2).
Table 2.
Comparison of prevalence of diarrhea and fever in recent three months among children with different time of introduction of CFs and different duration of breast-feeding (N, %)
| Time of introduction of CF | Duration of breast-feeding* | ||||||
|---|---|---|---|---|---|---|---|
| < 4 months | 4–8 months | > 8 months | < 12 months | 12–17.9 months | ≥ 18 months | ||
| Diarrhea | No | 34 (23.4) | 208 (35.7) | 20 (25.3) | 23 (34.8) | 32 (32.0) | 83 (28.9) |
| Yes | 111 (76.6) | 375 (64.3) | 59 (74.7) | 43 (65.2) | 68 (68.0) | 204 (71.1) | |
| OR (95% CI) | 1.8 (1.2, 2.8)† | Ref. | 1.6 (0.9, 2.8) | 1.0 (0.2, 3.9) | 0.8 (0.4, 1.5) | Ref. | |
| ORadjust-age (95% CI) | 1.9 (1.2, 2.8)† | Ref. | 1.5 (0.9, 2.6) | 1.0 (0.2, 3.9) | 0.8 (0.4, 1.5) | Ref. | |
| Fever | No | 20 (13.8) | 171 (29.3) | 19 (19.0) | 19 (28.8) | 27 (27.0) | 80 (27.9) |
| Yes | 125 (86.2) | 412 (70.7) | 64 (81.0) | 47 (71.2) | 73 (73.0) | 207 (72.1) | |
| OR (95% CI) | 2.6 (1.6, 4.3)† | Ref. | 1.8 (0.9, 3.2) | 2.8 (0.3, 22.2) | 0.58 (0.3, 1.1) | Ref. | |
| ORadjust-ages(95% CI) | 2.6 (1.6, 4.3)† | Ref. | 1.8 (1.0, 3.3)† | 2.8 (0.4, 22.6) | 0.58 (0.3, 1.1) | Ref. | |
CFs = complementary foods; CI = confidence interval; OR = odds ratio; ORadjust-age = age-adjusted odds ratio.
Only children older than 18 months were used for analysis (N = 453).
P < 0.05.
Considering different types of CFs, children who had not been introduced to grain had a higher prevalence of anemia (95.0%) compared to children who had already been introduced to grain (72.9%) (ORcrude = 10.0, 95% CI = 1.3, 75.4; ORadjust-age = 11.0, 95% CI = 1.3–89.7). There were no significant differences in wasting, stunting, being underweight, MUAC < −2 Z score, and small HC prevalence between children who had already been introduced to grain, egg, or meat and those who had not (Table 3). Diarrhea and fever prevalence showed no significant differences between children who had already been introduced to grain, egg, or meat and those who had not (Table 4).
Table 3.
Comparison of prevalence of wasting, stunting, underweight, MUAC < −2 z score and small HC between children who have been already introduced to grain, eggs, and meat or not (N, %)
| Grain | Egg | Meat | |||||
|---|---|---|---|---|---|---|---|
| No | Yes | No | Yes | No | Yes | ||
| Wasting | No | 16 (88.9) | 674 (86.6) | 82 (45.1) | 279 (44.6) | 118 (86.8) | 572 (86.7) |
| Yes | 2 (11.1) | 104 (13.4) | 100 (54.9) | 346 (55.4) | 18 (13.2) | 88 (13.3) | |
| OR (95% CI) | 1.2 (0.3, 5.5) | Ref. | 1.04 (0.63, 1.7) | Ref. | 1.0 (0.6, 1.7) | Ref. | |
| ORadjust-age (95% CI) | 1.3 (0.3, 7.0) | Ref. | 0.95 (0.5, 1.7) | Ref. | 1.1 (0.6, 2.1) | Ref. | |
| MUAC < −2 | No | 17 (85.0) | 735 (93.6) | 169 (92.9) | 583 (93.6) | 34 (24.5) | 180 (27.0) |
| Yes | 3 (15.0) | 50 (6.4) | 13 (7.1) | 40 (6.4) | 105 (75.5) | 87 (73.0) | |
| OR (95% CI) | 2.6 (0.7, 9.2) | Ref. | 0.9 (0.5, 1.7) | Ref. | 0.8 (0.4, 1.8) | Ref. | |
| ORadjust-age (95% CI) | 1.8 (0.3, 9.0) | Ref. | 1.0 (0.5, 2.1) | Ref. | 0.7 (0.3, 1.6) | Ref. | |
| Stunting | No | 10 (50.0) | 351 (44.6) | 82 (45.1) | 279 (44.6) | 63 (45.3) | 298 (44.6) |
| Yes | 10 (50.0) | 436 (55.4) | 100 (54.9) | 346 (55.4) | 76 (54.7) | 370 (55.4) | |
| OR (95% CI) | 0.8 (0.3, 2.0) | Ref. | 0.9 (0.7, 1.4) | Ref. | 1.0 (0.7, 1.4) | Ref. | |
| ORadjust-age (95% CI) | 0.8 (0.3, 2.4) | Ref. | 1.2 (0.8, 1.7) | Ref. | 1.2 (0.8, 1.8) | Ref. | |
| Underweight | No | 10 (50.0) | 476 (60.6) | 112 (61.9) | 374 (59.8) | 87 (63.0) | 399 (59.7) |
| Yes | 10 (50.0) | 310 (39.4) | 69 (38.1) | 251 (40.2) | 51 (37.0) | 269 (40.3) | |
| OR (95% CI) | 1.5 (0.6, 3.7) | Ref. | 0.9 (0.7, 1.3) | Ref. | 0.9 (0.6, 1.3) | Ref. | |
| ORadjust-age (95% CI) | 1.9 (0.7, 5.4) | Ref. | 1.0 (0.7, 1.5) | Ref. | 0.9 (0.6, 1.5) | Ref. | |
| HC < −2 z | No | 17 (85.0) | 674 (86.9) | 153 (85.5) | 538 (87.2) | 121 (88.3) | 570 (86.5) |
| Yes | 3 (15.0) | 102 (13.1) | 26 (14.5) | 79.(12.8) | 16 (11.7) | 89 (13.5) | |
| OR (95% CI) | 1.2 (0.3, 4.1) | Ref. | 1.2 (0.7, 1.9) | Ref. | 0.9 (0.5, 1.5) | Ref. | |
| ORadjust-age (95% CI) | 1.5 (0.3, 6.6) | Ref. | 1.2 (0.7, 2.1) | Ref. | 0.8 (0.4, 1.6) | Ref. | |
CI = confidence interval; HC = head circumference; MUAC = mid-upper arm circumference; OR = odds ratio; ORadjust-age = age-adjusted odds ratio.
Table 4.
Comparison of prevalence of diarrhea and fever in recent 3 months between children who have been already introduced to grain, eggs, and meat or not (N, %)
| Grain | Egg | Meat | |||||
|---|---|---|---|---|---|---|---|
| No | Yes | No | Yes | No | Yes | ||
| Diarrhea | No | 6 (30.0) | 256 (32.5) | 55 (30.2) | 207 (33.1) | 38 (27.3) | 224 (33.5) |
| Yes | 14 (70.0) | 531 (67.5) | 127 (69.8) | 418 (66.9) | 101 (72.7) | 444 (66.5) | |
| OR (95% CI) | 0.9 (0.3, 2.3) | Ref. | 0.9 (0.6, 1.3) | Ref. | 0.8 (0.5, 1.1) | Ref. | |
| ORadjust-age (95% CI) | 0.7 (0.2, 2.1) | Ref. | 0.8 (0.5, 1.2) | Ref. | 0.6 (0.4, 1.0) | Ref. | |
| Fever | No | 8 (40.0) | 198 (25.2) | 45 (24.7) | 161 (25.8) | 27 (19.4) | 489 (73.2) |
| Yes | 12 (60.0) | 589 (74.8) | 137 (75.3) | 464 (74.2) | 223 (80.6) | 224 (33.5) | |
| OR (95% CI) | 2.0 (0.8, 4.9) | Ref. | 1.0 (0.7, 1.4) | Ref. | 0.7 (0.4, 1.0) | Ref. | |
| ORadjust-age (95% CI) | 2.0 (0.7, 5.9) | Ref. | 1.0 (0.7, 1.6) | Ref. | 0.6 (0.4, 1.1) | Ref. | |
OR = odds ratio; ORadjust-age = age-adjusted odds ratio; CI = confidence interval.
Factors associated with maternal feeding behaviors.
Demographic characteristics of 642 mothers were collected and used for analysis of the potential factors that might be associated with feeding behavior. In a single factor analysis, the family's annual per capita income, education experience, parity in the past 3 years, and maternal anemia were associated with age of CFs introduction (Table 5). In multiple analyses, mothers who had anemia (B = 1.316, Wald = 17.824, OR = 3.7, 95% CI = 2.0–6.9) tended toward early CFs introduction. Women with a lower family income tended toward later introduction of CFs (B = 0.710, Wald = 8.445, OR = 2.0, 95% CI = 1.3–3.3).
Table 5.
Factors might be associated with time of introduction of CFs
| Variables | Time of introduction of CFs | P | |||
|---|---|---|---|---|---|
| < 4 months | 4–8 months | > 8 months | |||
| Family annual capita income (MMK) | < 3,000 | 19 (24.7) | 76 (21.8) | 54 (25.0) | 0.001 |
| 3,000–7,390.4 | 35 (45.5) | 131 (37.6) | 92 (42.6) | ||
| > 7,390.4 | 19 (24.7) | 14 (40.5) | 70 (32.4) | ||
| Number of family members | < 5 | 39 (50.6) | 147 (42.2) | 81 (37.3) | 0.301 |
| 6–10 | 35 (45.5) | 179 (51.4) | 124 (57.1) | ||
| > 10 | 3 (3.9) | 22 (6.3) | 12 (5.5) | ||
| Maternal education experience | Without primary education | 33 (42.9) | 115 (33.0) | 96 (44.2) | 0.018 |
| Primary education or above | 44 (57.1) | 233 (67.0) | 121 (55.8) | ||
| Maternal age | 18–30 | 55 (71.4) | 238 (68.4) | 146 (67.3) | 0.798 |
| > 30 | 22 (28.6) | 110 (31.6) | 71 (32.7) | ||
| Parity in recent 3 years | 1 | 69 (89.6) | 278 (79.9) | 161 (74.2) | 0.015 |
| ≥ 1 | 8 (10.4) | 70 (20.1) | 56 (25.8) | ||
| Maternal anemia | Yes | 48 (62.3) | 198 (56.9) | 146 (67.3) | < 0.001 |
| No | 29 (37.7) | 150 (43.1) | 71 (32.7) | ||
CFs = complementary foods; MMK = Myanmar Kyat.
Discussion
Feeding behaviors.
The 18-month period of CF, from approximately 6 to 24 months of age, makes up the largest proportion of the “1,000 day critical window.” During these dynamic months, the infant must make the transition to consuming a variety of textures and types of foods while meeting relatively high nutrient requirements.18 Promoting optimal CF practices in developing countries is a global health priority.19
However, based on previous reports, timely initiation of CF at the 6th month of age in developing countries, such as Ethiopia, Nairobi, and so forth, was usually under 50%.20 This study first reported the feeding behaviors of children in Myanmar and found inappropriate feeding behaviors that resulted in malnutrition.
On the one hand, 18.6% of the children in this study had been introduced to CFs early, which is higher than in Niger, Guinea, Burkina Faso, and Bangladesh.21,22 On the other hand, 32.0% of the children's introduction to CFs was later than 6 months of age, and 9.8% of the children were introduced even later than 8 months of age, which was lower than the data in Burkina Faso and Ghana but significantly higher than the data reported in Australia and the Yunan Province in China (Yunan geographically borders the investigated areas).23–26
Health effects of feeding behaviors.
A high prevalence of malnutrition was found in this survey, similar to our previous reports in 2012.7 Both early and late introduction of CFs led to a higher risk of malnutrition; however, the health effects were different.
A number of studies have reported that early introduction of CFs is associated with atopic diseases, obesity, and even adulthood chronic disease in developed countries and in infants in westernized and hygienic settings; however, data in developing countries are rare.18,27 In this study, children whose introduction to CFs was earlier than 4 months of age had a 1.7 and 1.6 times risk of being underweight (WAZ < −2 z score) or stunted (HAZ < −2 z score), respectively, compared with children who had a timely introduction to CFs. One study in rural Senegal reported similar findings that infants complemented at 2–3 months of age had significantly lower length for age and weight for length.28 However, one intervention study in Honduras did not find growth differences between children introduced to CFs at 4 and 6 months of age.7 We inferred that these controversial findings might be partly because of the maternal breast-feeding performance and the quality and safety of CFs. In the investigated population, anemia was found in 41.9% of the mothers, possibly leading to poor early breast-feeding performance. According to previous studies, children in the investigated areas usually had limited food diversity and poor sanitation.6,7 Introduction of CFs in resource-poor settings can result in diets that are nutritionally inadequate and microbiologically unsafe, leading to multiple nutrient deficiencies and the risk of exposure to foodborne pathogens, and, consequently, to gastrointestinal illnesses.29,30 A higher prevalence of infectious disease (diarrhea and fever) in studied children who had been introduced to CFs earlier than 4 months of age was also explored.
CFs introduction later than 8 months of age is a risk factor for anemia. Breast milk is well documented as a low-iron food, but infants up to 6 months of age can use their fetal iron storage when their mother had sufficient iron intake.31 After that, the risks of iron deficiency and iron deficiency anemia progressively increase.32 The WHO recommends iron-rich or iron-fortified foods for infants.33,34 Based on data in this study, children who had not been introduced to grain had a higher prevalence of anemia, and by the age of 24 months, there were still around 5% of children who had never been introduced to egg and meat, which are considered iron-rich foods. In combination with poor maternal health status that might result in low iron storage level in infants, children in the studied areas are under great threat of iron deficiencies.
The WHO recommends exclusive breast-feeding up to 6 months of age, with continued breast-feeding along with appropriate CF up to 2 years of age or beyond.35 There is compelling scientific evidence that optimal breast-feeding of infants over 1 year of age could prevent around a million deaths of children under the age of 5 years in the developing world36; however, data from the perspective of extended breast-feeding's effects on maternal health are limited, especially for women under a great threat of malnutrition and those with intensive pregnancy. Some anemia-prevalent countries like India have revealed that repeated pregnancies and lactation might aggravate anemia in women.37 In this study, we found that prolonged breast-feeding with CF (≥ 18 months) did not help children avoid malnutrition. In addition, an alarming rate of malnutrition in lactating Myanmar women was found in the studied areas.38 Further prospective studies are needed to explore health outcomes of the duration of breast-feeding in both children and lactating women and provide specific recommendations for areas like Myanmar.
Factors associated with feeding behaviors.
Mothers have a vital role in deciding feeding behaviors. Previous studies have reported that region, maternal age, maternal education experience, health education (or attending any antenatal clinics), parity, and both maternal physical and psychological statuses all might be associated with the introduction age of CFs.26,39–41 In this study, we found that poor maternal health status (maternal anemia) led to early introduction of CFs, and poor family economic status led to late introduction of CFs. A lack of education was found in the majority of women. According to the experience of developing countries, promoting women's health and implementing health education to mothers not only can change feeding behaviors, but also can change family well-being.42
Conclusion
The data in this study demonstrated that inappropriate feeding behaviors exist in children living in mountainous peripheral areas of Myanmar. Both early and late introduction of CFs might lead to health consequences in children. This study provided a clear picture of the next strategies needed for health promotion in these areas: 1) providing women with guidance regarding the science-based way of rearing babies, and the introduction of CFs neither earlier than 4 months of age nor later than 6 months of age; 2) timely introduction of iron-rich foods such as egg yolk and meat and relief foods such as nutrient-fortified infant formula, infant cereal and nutrient supplements should be provided when breast milk cannot meet the infant's need; 3) enhancing women's health to ensure good breast-feeding performance; and 4) further exploring the ideal duration of breast-feeding for achieving the most benefit for both children and women.
Limitations
A purposive sampling method was used to select three areas in Myanmar that were thought to have a poor health and economic status. A convenience sampling method was used to select villages that border China and were accessible. Thus, the data in this study can only represent the feeding behaviors of children in mountainous peripheral areas of Myanmar.
For data collection, because of the cross-sectional design, the recall bias was inevitable. In addition, the hygiene of the CFs was not evaluated. Therefore, the causality between disease occurring in the past 3 months and feeding behaviors could not been observed in this study. Based on a previous study, early introduction of CFs might expose infants to pathogenic microbes contained in unhygienic food or water.
ACKNOWLEDGMENTS
We sincerely appreciate the invaluable assistance of the local health officers with all of the provincial aspects of the survey. We would like to thank all of the local health professionals and HPA staff members who were involved in the fieldwork under tough working conditions. We want to give special acknowledgement to Li Bo, the regional representative of HPA in Kokang, Myanmar. Although conflict broke out again in 2015, Li Bo remained in Kokang to provide volunteer medical service to local children and sacrificed his life. The research team sincerely appreciates his support and coordination of the study and pays the highest tribute to his bravery and devotion to the health care of people in Kokang.
Footnotes
Authors' addresses: Ai Zhao and Peiyu Wang, Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, Beijing, China, E-mails: aizhaobjmu@gmail.com and xiaochaai@163.com. Hongchong Gao, School of Basic Medical Sciences, Capital Medical University, Beijing, PR China, E-mail: sisystone@gmail.com. Bo Li and Jun Zhang, Health Poverty Action Eastern Asia Program Office, Kunming, Yunnan, China, E-mails: boli_hu@163.com and junzhang_hpa@163.com. Naing Naing Win and Jiayin Li, Health Poverty Action Eastern Asia Program Office, Rangoon, Myanmar, E-mails: naingnaingwin_hpa@gmail.com and jiayinli_hpa@gmail.com. Yumei Zhang, Department of Nutrition and Food Hygiene, School of Public Health, Peking University Health Science Center, Beijing, China, and Beijing Key Laboratory of Toxicological Research and Risk Assessment for Food Safety, Beijing, PR China, E-mail: zhangyumei111@gmail.com.
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