Abstract
Background
Improper complementary feeding practices are common in India, thus leading to malnutrition. The objective was to compare complementary feeding practices of mothers with children aged between 6 months and 2 years before and after individualized nutritional counseling.
Methods
This before-and-after interventional study was carried out in a tertiary care teaching hospital between June 2018 and August 2018 on 30 mothers attending an immunization clinic. Feeding practices were assessed using interview techniques with the Breastfeeding Promotion Network of India Maharashtra checklist for Complementary Food Counseling (Diet Audit), and scoring was carried out. Baseline data included history of inclusion of items from food groups such as cereals; pulses; vitamins A, C, and D; vegetables/fruits; milk/dairy products; non-vegetarian items; and iron-rich foods; and consumption of baby feeds and junk foods. Individualized counseling was given to all study subjects, which lasted for 30–40 min. Models of various food items were shown to mothers. Feeding practices were reassessed after 4 weeks of one-to-one counseling.
Results
Feeding by mothers improved significantly in the form of items from the total number of groups from 4.3 (1.4) to 5.6 (1.3) after nutritional counseling (p: 0.001). Consumption of junk foods decreased significantly from 4.3 (2.8) to 2.6 (1.8; p: 0.001) and baby foods decreased from 0.8 (0.7) to 0.2 (0.4; p: 0.001).
Conclusion
Individualized nutritional counseling of mothers can improve complementary feeding practices and ensure food diversification.
Keywords: Complementary feeding, Nutritional counseling, Individualized counseling
Introduction
The period from birth to two years of age is the “critical window” for the promotion of good growth, health, and behavioral and cognitive development.1 Improper complementary feeding practices apart from malnutrition significantly increase risk of infectious diseases such as diarrhea and acute respiratory infections.2 Ensuring optimal complementary feeding has been documented as an essential step to prevent childhood malnutrition and under-five mortality and in turn attainment of Sustainable Development Goals.3 Appropriate and safe complementary feeding—ensuring that children are fed nutritionally rich complementary foods at the right age and at the right frequency and hygiene in feeding practices—is a major challenge in India. It is imperative that mothers along with caregivers and family members should be educated during all possible contacts about appropriate feeding practices and their role in maintenance of the child's health. The visit of the mother with the child to the immunization clinic is one such opportunity where she can be educated about the feeding of her child. The present study was undertaken to assess the role of individualized nutritional counseling in feeding practices by mothers while attending the immunization clinic.
Materials and methods
This was a before-and-after intervention study conducted in the immunization clinic of a government tertiary care hospital of western Maharashtra over a period of three months from June to August 2018. Ethical clearance for the study was obtained from the institutional ethical committee. Written informed consent was obtained from each subject. The subjects were mothers visiting the immunization clinic with children in the age-group of 6 months to 2 years. Mothers of children with HIV, chronic systemic illnesses, and congenital anomalies were excluded. Because there are no previous studies to study impact of nutritional counseling of mothers on infant and young child feeding (IYCF) practices, a sample of 30 was taken. Baseline data collection was carried out using the one-to-one interview method. The questionnaire was based on Maharashtra Breastfeeding Promotion Network of India (BPNI) guidelines, which included inclusion of 10 food groups in diet of children, namely, cereals, pulses, vitamin A, vegetables/fruits, milk/dairy products, eggs, mutton/chicken/fish, iron, vitamin C, and vitamin D, along with frequency and the method of feeding. The data on consumption of junk food were also collected.
Mothers were given individualized (one-to-one) counseling on correct IYCF practices. Models of food items to be consumed by the child were used to explain the subjects. We advised mothers to preferably keep the baby during daytime, in a room that had adequate sunlight. They were also advised to give foods rich in iron, vitamin A, and vitamin C. Health education for subjects on avoiding consumption of junk food was also provided. The mothers were called after 4 weeks, and the data were recollected on consumption of groups of food variables and junk food (Fig. 1). The data obtained were tabulated in MS Excel and analyzed using IBM SPSS 20 software.
Fig. 1.
Intervention and data collection. IYCF, infant and young child feeding; OPD, out patient department.
Results
The mean age of children was 14 ± 5.2 months. Distribution of the subjects based on sociodemographic variables is depicted in Table 1. Complementary feeding improved significantly in the form of items from 4.3 (1.4) to 5.6 (1.3) after nutritional counseling (p: 0.001). Similarly, consumption of junk foods decreased significantly from 4.3 (2.8) to 2.6 (1.8; p: 0.001) and baby foods decreased from 0.8 (0.7) to 0.2 (0.4; p:0.001) (Table 2). The number of mothers feeding vegetables and eggs and ensuring sunlight exposure increased significantly after counseling (p < 0.05) (Table 3). There was an absolute increase in the number of mothers feeding children with foods rich in iron. The decrease in the number of mothers in the vitamin A group might be due to consumption of vegetables other than those rich in vitamin A. If we consider vitamin A–rich food and vegetables together as a group, there was significant increase in intake of either of the two. Similarly, if we take eggs and non-vegetarian items as a group together, again, there was significant increase in intake of either of the two. Variables such as income of the family, education of the mother, and type of the family were not significantly associated with improvement in complementary feeding practices.
Table 1.
Distribution of the study subjects.
| Variable | Frequency | % |
|---|---|---|
| Socioeconomic status | ||
| Low | 12 | 40.0 |
| Medium | 15 | 50.0 |
| High | 3 | 10.0 |
| Maternal educational status | ||
| <5th | 2 | 6.7 |
| 5th–10th | 7 | 23.3 |
| 11th–12th | 9 | 30.0 |
| Graduate and higher | 12 | 40.0 |
| Maternal occupation | ||
| Working | 2 | 6.7 |
| Housewife | 28 | 93.3 |
| Type of delivery | ||
| Vaginal | 19 | 63.3 |
| LSCS | 11 | 36.7 |
| Parity | ||
| Nullipara | 1 | 3.3 |
| Multipara | 29 | 96.7 |
| Type of family | ||
| Nuclear | 16 | 53.3 |
| Joint | 14 | 46.7 |
| Initiation of breast feeding | ||
| <30 min | 1 | 3.3 |
| 30 min–1 hr | 9 | 30 |
| 1 hr–3 hr | 20 | 66.7 |
| Initiation of complementary feeds | ||
| <6 m | 1 | 3.3 |
| 7 m | 25 | 92.4 |
| 8 m | 3 | 10 |
| 9 m | 1 | 3.3 |
LSCS, Lower Segment Cesarean Section.
Table 2.
Comparison of total groups fed, junk food items fed, and baby foods used before and after counseling (n = 30).
| Food groups/items | Mean | Standard deviation | Standard error of the mean | T | p value |
|---|---|---|---|---|---|
| Total food groups fed before | 4.33 | 1.446 | 0.264 | −4.678 | 0.001 |
| Total food groups fed after | 5.67 | 1.295 | 0.237 | ||
| Total food items from junk food before | 4.30 | 2.806 | 0.512 | 4.650 | 0.001 |
| Total food items from junk food after | 2.60 | 1.812 | 0.331 | ||
| Food items from the baby feed group before | 0.87 | 0.776 | 0.142 | 5.135 | 0.001 |
| Food items from the baby feed group after | 0.20 | 0.407 | 0.074 |
Table 3.
Comparison of food groups consumed by the children before and after counseling.
| S. No. | Food group | Number of mothers feeding (before) | Number of mothers feeding (after) |
|---|---|---|---|
| 1 | Cereals | 29 | 28 |
| 2 | Pulses | 26 | 25 |
| 3 | Vitamin A | 11 | 06 |
| 4 | Vegetablesa | 05 | 21 |
| 5 | Dairy products | 29 | 30 |
| 6 | Egga | 07 | 18 |
| 7 | Non-vegetarian | 03 | 01 |
| 8 | Vitamin C | 08 | 08 |
| 9 | Iron | 05 | 08 |
| 10 | Vitamin Da | 07 | 25 |
Significant increase in the number of mothers who started feeding from these groups.
Discussion
Complementary feeding is the feeding process that takes place during the transition period after six months of exclusive breast feeding and before graduating to regular family food by 18–24 months of age. The prevalence of optimal complementary feeding as per National Family Health Survey (NFHS) - 4 is dismal; breastfeeding children aged 6–23 months receiving an adequate diet is 10.1%, and non-breastfeeding children aged 6–23 months receiving an adequate diet is 16.9% only.4 Dietary diversification is an important component of correct feeding.5 In the rural health-care setup, various health-care workers, viz, accredited social health activists, auxiliary nurse midwife, and Anganwadi workers, have been entrusted with the responsibility of nutritional counseling to pregnant and lactating mothers under the umbrella of the National Health Mission and Integrated Child Development Services (ICDS) program.6 Mothers in urban areas and slums remain largely unaware, and for a mother/caretaker, knowledge of feeding is restricted to satisfying the hunger of the child only. These mothers often turn to family/community elders and traditional practices to feed their children. Although mothers do receive diet counseling for the child while visiting outpatient department (OPD) for sickness of their children, it is often restricted to the period of sickness only. A heavy outpatient department (OPD) load along with time constraints is also responsible for lack of nutritional counseling to mothers for routine feeding of a child.7
We found complementary feeds to have been initiated, although incomplete, in 92.4% of children by the 7th month of life. One possible reason could be that 70% of the mothers were educated beyond class X, and another 23.3% had education levels between classes V and X. This must have helped them in being aware about the need for starting complementary feeds in time. Researchers have suggested that maternal education and employment are important factors for timely introduction of complementary feeds. In the study from Islamabad, where 500 mothers were inquired about infant feeding practices after 6 months, those mothers following poor complementary feeding practices had virtually no school education.8 A child in the age range of 6–23 months should be fed food from four or more food groups, other than receiving milk or milk products.9 In a country such as India, where the rates of children aged 6–23 months receiving an adequate diet are merely 11.6%,4 the results of our study are significant, in that the nutritional counseling by health-care workers helped in adopting good nutritional feeding practices. As shown in the study by Malhotra,10 nutritional advice on infant feeding practices provided by health professionals was strongly correlated with improved feeding practices in children aged 6–18 months. Similarly, in the study from Bihar, in which frontline workers provided nutritional counseling services, it resulted in better age-appropriate frequency of feeding.11
The strengths of our study were that it was a pilot study, and we did not come across any previous study to have assessed the role of nutritional counseling based on the questionnaire based on the Maharashtra BPNI audit. Second, we could also assess the role of individualized nutritional counseling in decline of consumption of junk food. Our study has some limitations. The sample size was small. We did not assess the effect of the intervention on growth of the children who were studied as the duration of study was inadequate and sample size was underpowered. Long-term follow-up would also have been useful in assessing whether the parents continued adhering to nutritional advice or not.
Conclusions
Individual nutritional counseling of mothers can improve complementary feeding practices of their children, ensuring food diversification and reducing intake of junk food. In future, a longer study with an adequate sample size is warranted to study the effects of nutritional counseling on growth and other clinical outcomes.
What this study adds?
Individual nutritional counseling of mothers can improve complementary feeding practices of their children, ensuring food diversification and reducing intake of junk food.
Financial interests
The study received grant from Indian Council of Medical Research (ICMR) Short Term Studentship (STS) grant reference ID 201807232.
Disclosure of competing interest
The authors have none to declare.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.mjafi.2020.10.004.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
References
- 1.Jones A.D., Ickes S.B., Smith L.E. World Health Organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings. Matern Child Nutr. 2014;10:1–7. doi: 10.1111/mcn.12070. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Walker C.L., Rudan I., Liu L. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381:1405–1416. doi: 10.1016/S0140-6736(13)60222-6. Epub 2013 Apr 12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Gupta A., Thakur N. Infant and young feeding practices in India: current status and progress towards SDG targets. Proc Indian Nat Sci Acad. 2018;84:853–865. [Google Scholar]
- 4.Sheet I.F. International Institute for Population Studies; 2017. NFHS-4 (National Family Health Survey-4) [Google Scholar]
- 5.Chiutsi-Phiri G., Heil E., Kalimbira A.A. Reduced morbidity motivated adoption of infant and young child feeding practices after nutrition education intervention in rural Malawi. Ecol Food Nutr. 2017;56:329–348. doi: 10.1080/03670244.2017.1338181. [DOI] [PubMed] [Google Scholar]
- 6.Kapil U. Integrated Child Development Services (ICDS) scheme: a program for holistic development of children in India. Indian J Pediatr. 2002;69:597–601. doi: 10.1007/BF02722688. [DOI] [PubMed] [Google Scholar]
- 7.Bajpai V. The challenges confronting public hospitals in India, their origins, and possible solutions. Adv Publ Health. 2014;2014 [Google Scholar]
- 8.Liaqat P., Rizvi M.A., QayyumA Ahmed H. Association between complementary feeding practice and mothers education status in Islamabad. J Hum Nutr Diet. 2007;20:340–344. doi: 10.1111/j.1365-277X.2007.00791.x. [DOI] [PubMed] [Google Scholar]
- 9.Complementary feeding: World Health Organization; [updated July 27, 2015]. Available from: http://www.who.int/elena/titles/complementary_feeding/en/.
- 10.Malhotra N. Inadequate feeding of infant and young children in India: lack of nutritional information or food affordability? Publ Health Nutr. 2010;16:1723–1731. doi: 10.1017/S1368980012004065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Das A., Mahapatra S., Sai Mala G., Chaudhuri I., Mahapatra T. Association of frontline worker provided services with change in block level complementary feeding indicators: an ecological analysis from Bihar, India. PloS One. 2016;11 doi: 10.1371/journal.pone.0166511. [DOI] [PMC free article] [PubMed] [Google Scholar]
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