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. 2019 Jul 29;15(4):e12862. doi: 10.1111/mcn.12862

Greater household food insecurity is associated with lower breast milk intake among infants in western Kenya

Joshua D Miller 1, Sera L Young 1,✉, Godfred O Boateng 2, Shadrack Oiye 3, Victor Owino 4
PMCID: PMC6800760  NIHMSID: NIHMS1037530  PMID: 31222968

Abstract

Household food insecurity has been hypothesized to negatively impact breastfeeding practices and breast milk intake, but this relationship has not been rigorously assessed. To generate an evidence base for breastfeeding recommendations among food‐insecure mothers in settings where HIV is highly prevalent, we explored infant feeding practices among 119 mother–infant dyads in western Kenya at 6 and 24 weeks postpartum. We used the deuterium oxide dose‐to‐the‐mother technique to determine if breastfeeding was exclusive in the prior 2 weeks, and to quantify breast milk intake. Sociodemographic data were collected at baseline and household food insecurity was measured at each time point using the Household Food Insecurity Access Scale. Average breast milk intake significantly increased from 721.3 g/day at 6 weeks postpartum to 961.1 g/day at 24 weeks postpartum. Household food insecurity at 6 or 24 weeks postpartum was not associated with maternal recall of exclusive breastfeeding (EBF) in the prior 24 hr or deuterium oxide‐measured EBF in the prior 2 weeks at a significance level of 0.2 in bivariate models. In a fixed‐effects model of quantity of breast milk intake across time, deuterium oxide‐measured EBF in the prior 2 weeks was associated with greater breast milk intake (126.1 ± 40.5 g/day) and every one‐point increase in food insecurity score was associated with a 5.6 (±2.2)‐g/day decrease in breast milk intake. Given the nutritional and physical health risks of suboptimal feeding, public health practitioners should screen for and integrate programs that reduce food insecurity in order to increase breast milk intake.

Keywords: breast milk intake, deuterium oxide dose‐to‐the‐mother, exclusive breastfeeding, food insecurity, HIV, sub‐Saharan Africa

Key messages.

  • Household food insecurity was not associated with maternal recall of exclusive breastfeeding or deuterium oxide‐measured exclusive breastfeeding at 6 or 24 weeks postpartum in this cohort.

  • Greater household food insecurity was associated with decreased breast milk intake among infants in this cohort.

  • Screening for and integrating programs that reduce food insecurity may increase quantities of breast milk ingested.

1. INTRODUCTION

Human milk provides optimal nutrition for infants (Lessen & Kavanagh, 2015). Exclusive breastfeeding (EBF) for the first 6 months of life reduces the risk of all‐cause mortality for children (Sankar et al., 2015) and confers numerous health benefits for mothers (Chowdhury et al., 2015; Kramer & Kakuma, 2012; Victora et al., 2016). Among HIV‐exposed infants, EBF is protective against morbidity and mortality (Rollins et al., 2013), and decreases the risk of HIV transmission through breast milk compared with mixed feeding (Manji et al., 2016). Therefore, the World Health Organization recommends that all infants should be exclusively breastfed for the first 6 months of life, irrespective of maternal HIV status (World Health Organization & UNICEF, 2016). Despite these guidelines, suboptimal breastfeeding practices are common globally (Global Breastfeeding Collective, 2018).

Prevalence and duration of EBF is suboptimal in Kenya. In 2014, only 61.4% of infants aged 0–5 months were exclusively breastfeed (Kenya National Bureau of Statistics, 2015). Previous qualitative and quantitative research in Kenya has identified inadequate breastfeeding knowledge (Ratnayake & Rowel, 2018), stigma related to HIV (Odeny et al., 2016), poverty, and lack of maternal autonomy over infant feeding practices as barriers to EBF (Nabwera et al., 2017).

Household food insecurity has been proposed as a determinant of EBF (Webb‐Girard et al., 2012; Young et al., 2014). Studies in Uganda (Young, Plenty, et al., 2014) and Canada (Orr, Dachner, Frank, & Tarasuk, 2018) found that moderate to severe household food insecurity was associated with earlier cessation of EBF. Conversely, a study in Haiti found that extremely food‐insecure mothers who were unable to purchase complementary foods exclusively breastfed their infants longer than food‐secure mothers (Lesorogol, Bond, Dulience, & Iannotti, 2018). Given that approximately 770 million individuals were exposed to severe food insecurity in 2017 (FAO, 2018), and that climate change is projected to undermine progress in food production and access (Wheeler & von Braun, 2013), it is imperative to understand how food insecurity impacts infant feeding practices. To date, however, no studies have investigated the relationship between food insecurity and an objective measure of EBF or quantity of breast milk ingested.

Nascent literature suggests that household food insecurity may negatively impact the amount of human milk a child receives through numerous pathways. Perceptions of breast milk sufficiency and maternal breastfeeding self‐efficacy may be harmed by exposure to food insecurity (Nabwera et al., 2017; Webb‐Girard et al., 2012). Physiologically, food insecurity may negatively impact breast milk quantity through several mechanisms. First, household food insecurity is associated with decreased maternal dietary diversity (Na et al., 2016) and undernutrition (Mastiholi et al., 2018; Motbainor, Worku, & Kumie, 2017), such that breast milk production or nutrient content may be compromised. Additionally, household food insecurity is associated with greater maternal psychosocial stress (Garcia et al., 2013). Increased stress can impair lactogenesis and may lower oxytocin, thereby limiting milk letdown and output (Dewey, 2001; Stuebe, Grewen, & Meltzer‐Brody, 2013). Further, food insecurity may compel mothers to seek employment outside the household or work for a greater proportion of the day, thereby disrupting normal feeding patterns and limiting the frequency and duration of feeding (Abou‐ElWafa & El‐Gilany, 2018; Nkrumah, 2016).

To generate an evidence base for breastfeeding recommendations among food‐insecure mothers, we explored breastfeeding practices among 119 mother–infant dyads in western Kenya at 6 and 24 weeks postpartum using the deuterium oxide dose‐to‐the‐mother (DTM) technique to quantify breast milk intake. The DTM technique is more precise than test weighing (Coward, Whitehead, Sawyer, Prentice, & Evans, 1979) and also provides an objective measure of whether an infant is exclusively breastfed (Owino, Slater, & Loechl, 2017). Our first objective was to explore the relationship between food insecurity and EBF. We hypothesized that greater food insecurity would be associated with a lower prevalence of EBF at 6 and 24 weeks postpartum. Further, we sought to examine potential differences in breast milk intake by food insecurity status across time. We hypothesized that greater household food insecurity would be associated with lower quantities of human milk being ingested.

2. METHODS

2.1. Study setting and population

Data were drawn from a prospective cohort study that was designed to compare differences in breast milk intake between HIV‐uninfected infants whose mothers were either HIV‐infected or ‐uninfected at enrolment (PACTR201807163544658). Recruitment criteria and the study design have been described elsewhere (Oiye, Mwanda, Mugambi, Filteau, & Owino, 2017). Briefly, mothers (n = 143) attending the Maternal and Child Health Clinic of Siaya County Referral Hospital in western Kenya for infant vaccinations at 6‐weeks postpartum were recruited into the study between February and September 2014. Women were eligible for inclusion if they planned to live in Siaya District for the following 10 months and their infants were both 6 weeks of age (±8 days) and HIV‐uninfected at enrolment. Women were excluded if their infants had low birthweight (<2,500 g), were born preterm, and/or were unable to breastfeed. Women were systematically sampled to detect differences in breast milk intake by maternal HIV status at a power of 0.8 (i.e., women living with HIV were oversampled), allowing for an expected 33% loss to follow‐up.

This was an appropriate setting to examine the impacts of food insecurity and HIV on breast milk intake because 34.0% of households in the region were food insecure (Siaya County Integrated Development Plan 2013–2017, 2014). Additionally, at the time of study enrolment, the prevalence of HIV among women of reproductive age in Siaya County was nearly four times the national average (Kenya Ministry of Health, 2014).

2.2. Survey data collection

Survey data were collected at 6 and 24 weeks postpartum by local clinic‐based study nurses using a structured paper questionnaire. Sociodemographic data (e.g., age, highest level of education), delivery information, and infant feeding practices were based on maternal recall. Following WHO guidelines, EBF was defined as an infant solely receiving breast milk, except for medically prescribed oral rehydration salts, drops, and/or syrups (vitamins, minerals, medicines) (World Health Organization, 2008). Date of birth and infant birthweight were obtained from both mother and child clinic cards when available, otherwise they were obtained by maternal recall. Anthropometric measurements were taken following standard protocols, as described elsewhere (Oiye et al., 2017).

Household food insecurity was measured using the Household Food Insecurity Access Scale (range: 0–27; Coates, Swindale, & Bilinsky, 2007), which prompts about experiences of food insecurity in the past 4 weeks. A subset of these items was used to measure household hunger (range: 0–6; Ballard, Coates, Swindale, & Deitchler, 2011). Households were then classified as having low (0–1), moderate (2–3), or high (4–6) hunger.

2.3. Maternal and infant HIV testing

Maternal HIV status was assessed at 6 and 24 weeks postpartum using colloidal gold antibody tests (KHB Shanghai Kehua Bioengineering Co. Ltd). At 6 weeks of age, each infant's serostatus was assessed with HIV‐1 DNA polymerase chain reaction (PCR) using a T100 Thermal Cycler (Bio‐Rad Laboratories Inc, UK). Infant HIV status was not assessed at 24 weeks because Kenyan government guidelines require HIV‐exposed infants to be tested at 9 months of age (Kenya Ministry of Health, 2012). On the basis of antibody and PCR‐confirmatory tests at 9 months, two infants seroconverted and were therefore excluded from analysis.

2.4. Determination of breast milk intake and EBF

Breast milk intake was measured at 6 and 24 weeks postpartum using the DTM technique, as described by the International Atomic Energy Agency (IAEA) (International Atomic Energy Agency, 2010). This method for measuring breast milk intake has been shown to be effective in similar East African settings (Ettyang, van Marken Lichtenbelt, Esamai, Saris, & Westerterp, 2005; Getahun et al., 2017). After being weighed, baseline (pre‐dose) saliva samples were collected from the mother and the infant (day 0) using a syringe and sterile cotton wool. Mothers then consumed a 30‐g oral dose of deuterium oxide (D2O) through a straw and were instructed to feed their infant as usual. At least 2 ml of saliva samples were subsequently collected from both the mother and infant in 10‐ml polypropylene sterile tubes on days 1, 2, 3, 4, 13, and 14. Post‐dose saliva was collected at the same time of day as at baseline collection. All samples were separately secured in ziplocked polythene bags and immediately frozen in −20°C freezers.

Samples were then transported in iceboxes to the Kenya Medical Research Institute (KEMRI) Nutrition Laboratory in Nairobi for analysis. Deuterium enrichment in mother and infant saliva over a 14‐day period was measured using a Fourier Transform Infrared Spectrophotometer (FTIR 8400 Series; Shimadzu Corporation, Kyoto, Japan). Deuterium enrichment was in turn used to calculate maternal total body water, from which breast milk output was derived using computer modelling (International Atomic Energy Agency, 2010). Infant intake of water from sources other than breast milk was calculated using a spreadsheet developed by the IAEA (International Atomic Energy Agency, 2010). Infants were considered EBF using the DTM technique if they consumed <25 g of water from sources other than human milk per day, as recommended by the IAEA (International Atomic Energy Agency, 2010). No mothers reported giving oral rehydration salts to their infants at either time point, such that this was an appropriate cut‐off.

2.5. Data cleaning and analysis

Survey and biomarker data were entered into Epi Info Version 6 and cleaned using both Microsoft Excel and Stata 14.0 (StataCorp, College Station, TX, USA). Descriptive statistics (chi‐square, t tests) were performed using Stata 14.0 with a significance level of .05. Significant covariates (p < .2) of EBF or human milk intake in bivariate analyses were included in multivariable linear regressions for each time point; variables were eliminated using a backwards stepwise approach (p < .1). Model specification was evaluated using the link test.

To examine the impact of food insecurity on breast milk intake over time, a fixed effects model was built using a similar stepwise technique. Given our restricted sample size, a bootstrap draw of 5,000 was used to check the asymptotic normality assumption, make accurate inferences about the broader population, and develop robust confidence intervals (Carpenter & Bithell, 2000). All models of breast milk intake were adjusted for deuterium‐oxide measured EBF.

2.6. Ethics

The Kenyatta National Hospital/University of Nairobi Ethics and Research Committee (KNH/UON/ERC) approved this study. The approval reference number is KNH‐ERC/A/90 (P517/09/2012). All participants provided written informed consent.

3. RESULTS

3.1. Characteristics of mother–infant dyads

One hundred forty‐three mother‐infant dyads were recruited into the study. Across the study period, 19 mother‐infant dyads were lost to follow‐up and two dyads were excluded from analysis after infant seroconversion was detected at 9 months (Figure 1). Although 122 mother‐infant dyads completed the study and met inclusion criteria, breast milk intake data were incomplete for three dyads. Therefore, given the study objectives, only the 119 mother–infant dyads with complete breast milk intake data were included for analysis.

Figure 1.

Figure 1

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Progress of mother–infant dyads through the study

A majority of participants (66.1%) lived in rural villages, the rest in towns. Most mothers were married (81.2%), did not complete secondary schooling (77.3%), were multiparous (81.5%), had a vaginal birth (91.6%), and delivered at a clinic (84.9%). Infant sex was nearly 1:1 (48.7% female). Maternal sociodemographic characteristics were similar by HIV status, although mothers living with HIV were slightly older than HIV‐negative mothers (Table 1). Additionally, household food insecurity scores decreased significantly between 6 and 24 weeks (mean ± SD, 7.7 ± 7.9 vs. 5.6 ± 6.7; p < .001).

Table 1.

Sociodemographic and health characteristics of mother–infant dyads (n = 119) at baseline, by maternal HIV status

Characteristics HIV− (n = 60) HIV+ (n = 59) p value
Residence, %
Town 33.3 34.5 .895
Village 66.7 65.5
Household food insecurity score (0–27), mean (SD) 6.3 (7.7) 8.4 (7.9) .141
Maternal age, mean (SD) 25.2 (6.2) 28.8 (6.3) .003
Maternal percent fat mass, mean (SD) 20.9 (10.1) 21.5 (9.7) .759
Maternal BMI, mean (SD) 22.6 (3.4) 22.5 (3.4) .890
Marital status, %
Single 23.3 14.0 .198
Married 76.7 86.0
Education, %
<secondary 70.0 84.8 .055
Primigravidae, % 21.7 13.6 .246
Caesarean delivery, % 10.0 6.8 .527
Place of delivery, %
Home 15.0 15.3 .969
Clinic 85.0 84.8
Infant sex, %
Female 50.0 47.5 .781
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3.2. Food insecurity and exclusive breastfeeding

As reported elsewhere (Oiye et al., 2017), 24‐hour maternal recall of EBF was lower at 24 weeks postpartum (69.2%) than 6 weeks postpartum (86.6%). Deuterium oxide‐measured EBF in the prior 2 weeks was greater at 24 weeks than 6 weeks postpartum (33.3% vs. 19.3%; Oiye et al., 2017).

In bivariate analyses, neither maternal recall of EBF nor deuterium oxide‐measured EBF were significantly associated with household food insecurity or household hunger at 6 weeks postpartum (Table 2). At 24 weeks postpartum, greater food insecurity and household hunger were associated with a 5% and 32% increase in the odds of deuterium oxide‐measured EBF at a significance level of .2, respectively (Table 2). However, neither food insecurity nor household hunger were associated with EBF at either 6 or 24 weeks postpartum in multivariable models adjusting for other maternal sociodemographic characteristics that were significant at p < .2 (data not shown).

Table 2.

Exploratory bivariate associations between food insecurity and EBF at 6 and 24 weeks postpartum

Predictors of EBF at 6 weeks postpartum (n = 119) Maternal recall of EBF in the prior 24 hours Deuterium oxide‐measured EBF in the prior 2 weeks
Coefficient [80% CI] p value Coefficient [80% CI] p value
Household food insecurity score (0–27) 0.99 [0.94, 1.03] .665 0.99 [0.96, 1.03] .842
Household food insecurity
Moderate — — 0.85 [0.39, 1.87] .792
High 0.47 [0.20, 1.10] .256 0.59 [0.21, 1.65] .511
Household hunger score (0–6) 0.93 [0.76, 1.13] .629 0.99 [0.82, 1.19] .927
Household hunger
Moderate 2.81 [0.71, 11.10] .337 1.13 [0.51, 2.51] .845
High 0.42 [0.16, 1.08] .238 0.94 [0.33, 2.72] .942
Predictors of EBF at 24 weeks postpartum (n = 119) Maternal recall of EBF in the prior 24 hours Deuterium oxide‐measured EBF in the prior two weeks
Coefficient [80% CI] p value Coefficient [80% CI] p value
Household food insecurity score (0–27) 1.03 [0.99, 1.07] .367 1.05 [1.01, 1.09] .106
Household food insecurity
Moderate 1.55 [0.70, 3.44] .478 2.27 [1.12, 4.61] .138
High 1.55 [0.52, 4.61] .603 2.27 [0.87, 5.90] .272
Household hunger score (0–6) 0.99 [0.80, 1.22] .932 1.32 [1.07, 1.61] .082
Household hunger
Moderate 1.79 [0.75, 4.29] .393 2.68 [1.30, 5.51] .080
High 0.22 [0.05, 1.10] .229 4.69 [0.95, 23.11] .214
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Abbreviation: CI, confidence interval; EBF, exclusive breastfeeding.

3.3. Food insecurity and breast milk intake

Breast milk intake ranged from 431.3 to 1,321.5 g/day for infants aged 6 weeks and 705.5 to 1,270.0 g/day for infants aged 24 weeks. Overall, breast milk intake increased significantly as infants aged (p < .001).

At 6 weeks postpartum, infants from households with high household hunger consumed significantly less breast milk (−57.7 ± 37.3 g/day) than infants from households with low household hunger at a significance level of .2 (Table 3). Using cross‐sectional data from 24 weeks postpartum, moderate household food insecurity was associated with greater breast milk intake (51.1 ± 31.9 g/day) at a significance level of .2 (Table 3). However, neither food insecurity nor household hunger were associated with breast milk intake at either 6 or 24 weeks postpartum in multivariable models adjusting for other maternal sociodemographic characteristics that were significant at p < .2 (data not shown).

Table 3.

Exploratory bivariate associations between food insecurity and quantity of breast milk ingested at 6 and 24 weeks postpartum

Predictors of breast milk intake at 6 weeks Coefficient [80% CI] p value
Household food insecurity score (0–27) −1.4 [−3.1, 0.4] .330
Household food insecurity
Moderate 5.1 [−32.3, 42.5] .861
High −33.5 [−76.4, 9.4] .316
Household hunger score (0–6) −4.6 [−13.2, 4.1] .497
Household hunger
Moderate 37.7 [−1.15, 76.7] .214
High −57.7 [−105.8, −9.6] .125
Predictors of breast milk intake at 24 weeks Coefficient [80% CI] p value
Household food insecurity score (0–27) 0.7 [−1.4, 2.9] .665
Household food insecurity
Moderate 51.1 [10.0, 92.3] .112
High −15.7 [−71.5, 40.1] .717
Household hunger score (0–6) 6.3 [−5.1, 17.6] .477
Household hunger
Moderate 32.1 [−9.5, 73.7] .321
High 39.4 [−48.4, 127.3] .564
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However, in the final fixed‐effects model of breast milk intake across time, with a bootstrap draw of 5,000, every one‐point increase in food insecurity score was associated with a 5.6 (±2.2)‐g/day decrease in breast milk intake (Table 4). Additionally, EBF was associated with greater quantities of breast milk ingested (126.1 ± 40.5 g/day). Link tests were non‐significant across all models, suggesting appropriate model specification.

Table 4.

Predictors of breast milk intake 6 and 24 weeks postpartum among mother‐infant dyads in a multivariable fixed effects model, controlling for deuterium‐oxide measured EBF

Predictors of breast milk intake Coefficient [95% CI] p value
Household food insecurity score (0–27) −5.6 [−10.0, −1.2] .012
EBF 126.1 [46.9, 205.4] .002
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Abbreviation: CI, confidence interval; EBF, exclusive breastfeeding.

4. DISCUSSION

Our first objective was to explore the relationship between food insecurity and EBF behaviour at 6 and 24 weeks postpartum. In contrast to our hypothesis, we found no significant relationship between food insecurity and maternal recall of EBF in the prior 24 hr or deuterium oxide‐measured EBF in the prior 2 weeks in multivariable models. This is consistent with previous research that found no relationship between food insecurity and duration of EBF among mothers in rural Bangladesh (Saha et al., 2008). However, our findings differ from work in Uganda, which reported a significant relationship between moderate to severe household hunger and lower odds of continuing EBF from 4 to 6 months (Young, Plenty, et al., 2014). Similarly, a study of Canadian mothers found that women from households with moderate or high food insecurity had lower odds of sustaining EBF to 6 months postpartum, although they used a different tool to measure food insecurity (Orr et al., 2018). These differences may also be a result of the different recall periods of EBF: our study measured EBF in the prior 24 hr and past 2 weeks, whereas other studies examined cumulative, sustained EBF across time.

Our second objective was to explore the relationship between the quantity of breast milk ingested and food insecurity status. We found that household food insecurity was not a significant predictor of breast milk intake in cross‐sectional multivariable models at 6 or 24 weeks postpartum. However, in longitudinal analysis, we found that greater household food insecurity was significantly associated with reduced breast milk intake across this critical period of infant feeding (Table 4). The quantities are biologically significant: a 20‐point increase in food insecurity would be associated with infants consuming 79.0 kcal fewer from breast milk (assuming 20 kcal/ounce [Sauer, Boutin, & Kim, 2017]). Further, a reduction in human milk intake could lead to micronutrient deficiencies.

To our knowledge, this is the first study adequately designed to examine the relationship between food insecurity and breast milk intake. Although a previous study found no relationship between maternal nutrition and breast milk quantity (Nazlee, Bilal, Latif, & Bluck, 2011), food insecurity (which considers both food access and use) and intake were not measured. Future research should explore the many plausible nutritional, psychosocial, and physiological pathways by which household food insecurity may influence breast milk intake (Webb‐Girard et al., 2012).

We also found a significant increase in the average quantity of breast milk ingested across time, from 721.3 g/day at 6 weeks postpartum to 961.1 g/day at 24 weeks postpartum. This trend was expected due to increases in infant size, and is consistent with findings from a review of 12 studies that measured breast milk intake using the DTM deuterium oxide technique; intakes increased from about 700 g/day at 1–2 months postpartum to over 800 g/day at 5–6 months postpartum (da Costa et al., 2010). Additionally, we found a positive, nutritionally significant relationship between EBF and quantity of human milk ingested across time (Table 4). This is supported by a previous study among Brazilian mother–infant dyads that found significantly higher intakes of breast milk among exclusively versus partially breastfed infants (Haisma et al., 2003).

Our findings have important implications for breastfeeding recommendations and public health messaging. First, we found that greater food insecurity was associated with reduced breast milk intake. The physiological, psychosocial, and economic pathways implicated in this relationship should be rigorously assessed in order to identify modifiable risk factors. Clinicians should also regularly screen for food insecurity; mothers from households with high food insecurity may require additional support to ensure proper infant feeding practices and promote greater breast milk intake. Additionally, practitioners, public health program developers, and policymakers should develop and implement promotional campaigns that target this vulnerable population.

Strengths of our study include its longitudinal design, large sample size, multiple objective measurements of breastfeeding behaviour, and use of stable isotopes to measure breast milk intake. Future studies could expand upon this work by measuring breast milk intake at multiple time points and using an individually focused food insecurity scale; our examination of household food insecurity may obscure intrahousehold differences in food access and intake (Akerele, 2011; Harris‐Fry et al., 2018). Examination of breast milk macro and micronutrient quality in relation to maternal food insecurity would also be informative.

5. CONCLUSION

We found that greater household food insecurity was associated with decreased breast milk intake among HIV‐uninfected infants in western Kenya. Given the nutritional and physical health risks of suboptimal feeding, as well as the numerous risks that food insecurity poses for women living with HIV (Ivers & Cullen, 2011; Koss et al., 2016; Young, Wheeler, McCoy, & Weiser, 2014), screening for and integrating programs that reduce food insecurity would likely increase breast milk intake.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

VO, SO, and SLY designed the study. VO and SO collected the data. GOB and JDM analysed the data. JDM wrote the first draft of the paper. All authors critically reviewed and revised the manuscript. All authors had responsibility for the final content.

ACKNOWLEDGMENTS

We would like to warmly thank project staff, as well as the mothers and their infants who participated in this study.

Miller JD, Young SL, Boateng GO, Oiye S, Owino V. Greater household food insecurity is associated with lower breast milk intake among infants in western Kenya. Matern Child Nutr. 2019;15:e12862 10.1111/mcn.12862

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