Appropriate feeding practices are the key contributor to reducing morbidities and mortalities in under-five children. A cross-sectional questionnaire based survey of mothers of children aged less than 5years was conducted in 781 mothers. More than half of mothers (57.5%) started feeding within an hour of birth, 55.9% gave exclusive breastfeeding for six months, 89.1% of the mothers stopped breastfeeding before two years of age, 18.2% of the mothers bottle-fed the babies, and 15.6% had problems during breastfeeding in first 6 months. Early initiation of breastfeeding within one hour of birth promoted exclusive breastfeeding, and breastfeeding for longer duration. Exclusive breastfeeding increased frequency of feeds. Multivariable logistic regression showed that initiation of breastfeeding after an hour of birth (
Appropriate Infant and Young Child Feeding (IYCF) practices are essential for optimal growth, cognitive development, and overall well-being in early vulnerable years of life. Malnutrition contributes to about 60% of under-five mortality worldwide annually and over two-thirds of these are due to inappropriate feeding practices [
The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life and the addition of complementary feeds from six months onwards, with continued breastfeeds till at least two years of age [
Apart from exclusive breastfeeding initially, time of introduction, content, and consistency of complementary feeds are critical for early nutrition. The early introduction of complementary feeds before the age of six months can lead to displacement of breast milk and increased risk of infections, besides the babies being physiologically immature. Similarly, inadequate and inappropriate complementary feeding with unhygienic practices leads to recurrent and persistent infections and malnutrition which is followed by growth retardation, immunodeficiency, and eventually fatal outcomes. This is a concern for Indian scenario, where previous studies have suggested inability to maintain exclusive breastfeeding and late introduction of complementary feeds [
Breastfeeding though is a natural act; it is a behavior that needs to be learned. Mothers and other caregivers need active assistance for optimum breastfeeding practices. The Global Strategy for Infant and Young Child Feeding describes the essential interventions to promote, protect, and support exclusive breastfeeding [
Multiple efforts are being envisaged to improve feeding practices in children. WHO and United Nations Children’s Fund (UNICEF) launched the Baby-Friendly Hospital Initiative in 1992, Integrated Management of Childhood Illness (IMCI) in mid-1990s, and IYCF in 2002 which stress the importance of breastfeeding. All these programs have been adopted by India since the last one to two decades to promote appropriate feeding practices in children under-five years.
Appropriate breastfeeding and complementary feeding practices depend on accurate information and support from the family, community, and healthcare system. Inadequate knowledge about feeding practices is an equally important determinant of malnutrition, as is the lack of adequate and hygienic food. However, in spite of all the efforts deployed as information, education, or training campaigns, the prevalence of proper feeding practices remains low [
India hosts more than one-third of the world’s children who are wasted. From under-five children in India, 43% are underweight and 48% are stunted due to chronic undernutrition. Only 25% of newborns were put to the breast within one hour of birth and 46% are exclusively breastfed [
Multiple factors are responsible for this slow improvement in nutritional health indicators in India. According to World Bank report, India’s Integrated Child Development Services (ICDS) needs to undergo significant changes to address the current malnutrition crisis in India [
As there is a paucity of literature on the feeding practices in this region, the present study was undertaken to assess the feeding practices of mothers having children under-five years of age. The interaction of sociodemographic variables with feeding practices and associations of childhood morbidity were studied.
This study is designed as a questionnaire based survey.
This study was conducted at the pediatrics outpatient department (OPD) catering to children from birth to 18 years of age attached to a tertiary care Shree Krishna Hospital (SKH) of Pramukhswami Medical College located at Karamsad from Anand district of Gujarat, India, over a period of four months from October 2013 to January 2014. The hospital caters to Anand and Kheda districts of Gujarat. Mothers having children less than five years of age attending the clinic for immunizations, growth monitoring, treatment of minor illnesses, health check-ups, follow-up, and so forth were interviewed after taking an informed consent. All children with known nonnutritional congenital or acquired reasons (e.g., congenital heart diseases, cerebral palsy, genetic disorders, and tuberculosis) of failure to thrive were excluded.
The questionnaire consisted of 39 questions on sociodemographic variables, feeding practices, and morbidities of children (hospitalization, diarrhea, and acute respiratory illnesses). Weight of the child was taken on a digital weighing scale of Zeal Medical Pvt. Ltd. Weight for age classification was used to estimate the nutritional status of children using the
Descriptive statistics were used to depict the sociodemographic characteristics, clinical profile, and feeding practices of the study population. Associations between feeding practices and sociodemographic variables as well as between feeding practices, sociodemographic variables, and hospital admissions at univariate level were determined using chi-square test. Multivariable logistic regression was performed to determine independent associations. Odds ratio (OR) was calculated and significance was considered at
The study was approved by human research ethics committee of HM Patel Centre for Medical Care and Education, Karamsad.
Out of 6385 children who visited pediatrics OPD between October 2013 and January 2014, 4416 (69.16%) were below 5 years of age. As the interviews were conducted between 10:00 h and 13:00 h, a total of 910 children could be approached. Out of these, 811 were accompanied by their mothers. Twenty-four mothers did not give consent due to time constraints while 6 were not eligible because of the known cause of failure to thrive (i.e., 3 had congenital heart diseases, 2 had cerebral palsy, and 1 had pulmonary tuberculosis). Thus 781 (97%) eligible mothers participated in the study.
The mean (SD) age of participating mothers was 27.18 (3.77) years (range: 19 to 42). Majority of mothers (86.1%) had studied up to 10th standard. Very few (2.6%) mothers had multifetal pregnancy. The monthly family income was quite skewed ranging from Rs. 2000 to Rs. 45000. Majority of the children belong to age group of six months to two years (54.8%) and had an older sibling (55.5%). The mean (SD) birth weight of the children was 2708.94 (510.92) grams (range: 900 to 4500). Most of them suffered from diarrhea (61.7%) and cough and cold (77.6%) and required hospitalization (41.9%) (Table
Sociodemographic variables.
Sociodemographic variable | Frequency |
---|---|
Age (years) of the mothers, mean (SD) | 27.18 (3.77), range: 19 to 42 years |
Mother’s education less than 4th standard | 109 of 780 (13.97%) |
Low birth weight children | 195 of 768 (25.4%) |
Monthly family income less than Rs. 15000 | 570 of 765 (74.5%) |
Multiparous mothers | 431 of 777 (55.5%) |
Number of children who required hospitalization | 327 of 781 (41.9%) |
Number of children who had diarrhea | 482 of 781 (61.7%) |
Number of children who had cough-cold | 606 of 780 (77.6%) |
Multifetal pregnancy | 17 of 778 (2.2%) |
Number of mothers who had problems during breastfeeding during first 6 months after delivery | 120 of 771 (15.6%) |
Family support for breastfeeding | 76 of 766 (10%) |
Male gender | 476 of 780 (61%) |
Bottle feeding | 142 of 771 (18.4%) |
Employed women | 138 of 779 (17.7%) |
Hindu religion | 653 of 779 (83.8%) |
Started breastfeeding within 1st hour of delivery | 443 of 771 (57.5%) |
Age of the child (of total 767) | |
Less than 6 months | 60 (7.8%) |
6 months to 24 months | 420 (54.8%) |
More than 24 months | 287 (37.4%) |
Use of soap to wash hands for children more than 6 months before feeding | 404 of 687 (58.8%) |
Washing utensils after each feed | 532 of 697 (76.3%) |
Washing hand of mother before each feed for children more than 6 months age | 499 of 692 (72.1%) |
Who feeds the child more than 6 months | |
Mother | 600 (86.3%) |
Other person | 95 (13.7%) |
Exclusive breastfeeding for 6 months in children more than 2 years | 160 of 286 (55.9%) |
Breastfeeding stopped less than 2 years of age in children more than 2 years | 253 of 284 (89.1%) |
As per WHO definition of nutritional status as per weight for age [
More than half of the mothers (57.5%) started breastfeeding within one hour of child’s birth, gave exclusive breastfeeding for recommended 6 months (55.9%), and continued to breastfeed in the second year of life (50.7%). Most mothers did not face any problem during breastfeeding in the first six months (84.4%) and did not bottle-feed the baby (81.6%). More than half of the mothers washed their hands (72.1%) before giving feeds and washed utensils after each feed (76.3%). Only 26.5% of the mothers who gave complementary feeds stored the food in oven or refrigerator and 42.2% always rewarmed the stored food before giving; however, 61.9% of the mothers often gave freshly prepared food. The complementary feed was given mostly by the mother (86.6%) (Table
Primiparous mothers and mothers with multifetal pregnancy started breastfeeding early. Mothers who breastfed their children within 1st hour of birth were more likely to give exclusive breastfeeding for 6 months, breastfeed for a longer duration, and engage in bottle-feeding the baby. Maternal education was not associated with time of starting breastfeeding. Mothers who exclusively breastfed their children for recommended period of 6 months gave breastfeeding for longer duration and frequently breastfed their child in a day (Tables
Univariate analysis for time of starting breastfeeding after birth in children more than 2 years.
Variables | When did breastfeeding start? |
| |
---|---|---|---|
After 1st hour of birth |
Within 1st hour of birth |
||
Elder siblings | |||
No | 129 (37.7) | 213 (62.3) | 0.018 |
More than/equal to 1 | 197 (46.2) | 229 (53.8) | |
Births | |||
Multifetal | 2 (12.5) | 14 (87.5) | 0.014 |
Single | 325 (43.2) | 428 (56.8) | |
Studied up to | |||
Less than 4th standard | 49 (45.4) | 59 (54.6) | 0.51 |
4th standard and above | 278 (42) | 384 (58) | |
Bottle feeding |
|||
No | 283 (86.8) | 346 (79.0) | 0.003 |
Yes | 43 (13.2) | 92 (21.0) | |
Duration of breastfeeding |
|||
Less than 2 years | 293 (97.1) | 371 (93.5) | 0.032 |
2 years or more | 9 (2.9) | 26 (6.5) | |
Exclusive breastfeeding |
|||
Other than 6 months/more than 1 year | 161 (49.1) | 171 (38.8) | 0.004 |
6 months | 167 (50.9) | 270 (61.2) |
Univariate analysis for exclusive breastfeeding in children more than 2 years.
Variables | Duration of exclusive breastfeeding |
|
|
---|---|---|---|
Other than 6 months |
6 months |
||
Problems in breastfeeding in first 6 months | |||
No | 101 (42.1) | 139 (57.9) | 0.095 |
Yes | 25 (55.6) | 20 (44.4) | |
Studied up to | |||
Less than 4th standard | 18 (46.2) | 21 (53.8) | 0.776 |
4th standard and above | 108 (43.7) | 139 (56.3) | |
Bottle-feeding | |||
No | 96 (42.9) | 128 (57.1) | 0.438 |
Yes | 30 (48.4) | 32 (51.6) | |
Occupation | |||
Employed | 22 (47.8) | 24 (52.2) | 0.574 |
Housewife | 104 (43.3) | 136 (56.7) | |
Sex of child | |||
Female | 56 (50.5) | 55 (49.5) | 0.083 |
Male | 70 (40.0) | 105 (60.0) | |
Religion | |||
Christian | 7 (50.0) | 7 (50.0) | 0.498 |
Hindu | 111 (44.9) | 136 (55.1) | |
Muslin | 8 (33.3) | 16 (66.7) | |
Nutrition | |||
Normal | 65 (40.4) | 96 (59.6) | 0.581 |
Moderate malnutrition | 21 (45.7) | 25 (54.3) | |
Overweight | 1 (50.0) | 1 (50.0) | |
Severe malnutrition | 35 (50.0) | 35 (50.0) | |
Duration of breastfeeding |
|||
Less than 6 Months | 47 (14.7) | 0 (0.0) | <0.0001 |
6 to 23 months | 260 (81.2) | 361 (94.2) | |
24 months or more | 13 (4.1) | 22 (5.8) | |
Number of breastfeeds per 24 hours |
|||
Less than 8 times | 270 (80.4) | 312 (71.5) | 0.005 |
8 times or more | 66 (19.6) | 124 (28.5) |
Multivariable logistic model revealed that initiation of breastfeeding within one hour, exclusive breastfeeding for six months, maternal employment, primipara status, mother feeding the child, and overweight significantly reduced hospital admissions. The predictive value of the model was good with 65.3% correct classification rate (Table
Variables associated with hospital admissions in children aged more than 6 months.
Variables |
|
OR | 95% CI for OR | |
---|---|---|---|---|
Lower | Upper | |||
Starting of breastfeeding | ||||
After an hour of birth | 0.035 | 1.482 | 1.027 | 2.138 |
Within hour (reference category) | ||||
Exclusive breastfeeding | ||||
6 months (reference category) | ||||
Less than 6 months or one year and more than 1 year | <0.0001 | 2.100 | 1.450 | 3.039 |
Occupation | ||||
Employed | 0.035 | 0.585 | 0.356 | 0.963 |
Housewife (reference category) | ||||
Elder siblings | ||||
One and more | 0.001 | 1.923 | 1.326 | 2.788 |
No (reference category) | ||||
Feeding given by | ||||
Mostly mother (reference category) | ||||
Other | 0.007 | 2.070 | 1.219 | 3.515 |
Nutritional status of children | 0.006 | |||
Moderate malnutrition | 0.939 | 1.024 | 0.562 | 1.866 |
Overweight | 0.011 | 0.441 | 0.233 | 0.831 |
Severe malnutrition | 0.052 | 1.578 | 0.996 | 2.499 |
Normal (reference category) |
Severe malnutrition, not starting breastfeeding within 1st hour of birth, and stopping breastfeeding before 2 years were associated with increased diarrhea episodes. The predictive value of the model was good with 67.5% correct classification rate (Table
Variables associated with diarrhea and cough/cold episodes in children age more than 6 months.
Variables |
|
OR | 95% CI for OR | |
---|---|---|---|---|
Lower | Upper | |||
Variables associated with diarrhea in children aged more than 6 months | ||||
Starting of breastfeeding | ||||
After an hour of birth | 0.045 | 1.479 | 1.009 | 2.166 |
Within hour (reference category) | ||||
Nutritional status of children | 0.029 | |||
Moderate malnutrition | 0.758 | 0.909 | 0.497 | 1.666 |
Overweight | 0.209 | 0.695 | 0.394 | 1.227 |
Severe malnutrition | 0.018 | 1.853 | 1.111 | 3.089 |
Normal (reference category) | ||||
Duration of breastfeeding | ||||
Up to 2 years | 0.026 | 2.506 | 1.114 | 5.638 |
2 years or more (reference category) | ||||
|
||||
Variables associated with cough and cold in children aged more than 6 months | ||||
Hand washing before each feed | ||||
Always (reference category) | ||||
Sometimes | 0.039 | 0.620 | 0.394 | 0.977 |
Nutritional status of child | 0.115 | |||
Moderate malnutrition | 0.590 | 1.221 | 0.590 | 2.527 |
Overweight | 0.636 | 1.182 | 0.591 | 2.363 |
Severe malnutrition | 0.015 | 2.135 | 1.159 | 3.933 |
Normal (reference category) | ||||
Washing utensils after each feed | ||||
After each feed (reference category) | ||||
Sometimes | 0.001 | 0.457 | 0.282 | 0.740 |
Occupation | ||||
Employed | 0.022 | 0.546 | 0.325 | 0.916 |
Housewife (reference category) |
Children of unemployed mothers and having severe malnutrition were more likely to encounter cough/cold episodes. Hygiene of hands and utensils showed inverse association with cough/cold episodes. The predictive value of the model was good with 79.5% correct classification rate (Table
Early initiation of breastfeeding and exclusive breastfeeding of children below six months are considered the most decisive indicators for assessing breastfeeding practices [
In the present study 57.5% of the children received breastfeeding within one hour of birth. Similarly a study done at Allahabad showed 55.8% of the mothers initiating breastfeeding within six hours [
Exclusive breastfeeding during the first 6 months and therefore timely introduction of complementary feeding have many proven advantages to both the mother and the child and are therefore the prime focus in infant feeding promotional activities. In our study we observed 55.9% of the infants exclusively breastfeed till complete six months. Similar rates were observed by Das et al. (58.7%) and Banapurmath et al. (60%) [
The NFHS-3 data for Gujarat state reports 93.5% of mothers breastfeeding between 6 and 9 months, which is similar to our data of 93.3% after 6 months. However, in the second year the breastfeeding rate observed in our study (50.7%) was lower than seen in NFHS-3 data (76.8%).
The rate of bottle-feeding was 18.4% similar to what was observed in NFHS-3 and in other studies. It is one of the optional indicators of IYCF practices. Bottle-feeding should be discouraged—bottles are difficult to clean and sterilize and are the source of infection, and artificial teats cause “nipple confusion” thus interfering with breastfeeding. The bottle-feeding was 11% in a study from urban population [
Maternal illiteracy has been associated with suboptimal feeding practices [
We did not find significant association of maternal occupation with initiation of breastfeeding and duration of exclusive breastfeeding despite housewives supposedly having more time available to feed their infants. One of the probable reasons for this is that working mothers carry their children at workplace and they are able to provide breastfeeding. A study in Malaysia reported that facility at workplace allowing mothers a flexible time to express breast milk helps in maintaining lactation [
In our study we found an association of multifetal births with initiation of breastfeeding within one hour of birth and no relation with duration of exclusive breastfeeding. However, small sample size in multiple pregnancies (
In our study primiparous mothers initiated breastfeeding earlier than multiparous mothers. Microbial contamination of feeds is a major cause of infections leading to higher hospital admissions. A study from Madhya Pradesh showed significant association of hygienic practices and malnutrition in infants [
We found an association between hospital admissions of children with feeding given by person other than mother. Study from Maharashtra showed feeding given by foster mothers (elder brother/sister) as a major determinant of faulty feeding practices [
We conclude that there has been slight improvement in feeding practices since the last NFHS survey in 2005-2006. However, the current rates of proper feeding practices are still well below the guidelines for Infant and Young Child Feeding. Late initiation of breastfeeding, nonexclusive breastfeeding, bottle-feeding, maternal illiteracy, and unhygienic feeding practices are still prevailing. Though more emphasis in terms of antenatal counseling, hospital delivery, and training of grass root workers on IYCF is being conducted to improve child feeding practices, they are still inadequate to improve short term and long term outcomes of childhood nutrition. There is an alarming need of a prospective educational intervention study or new innovative practices to achieve the optimum feeding practices in children under the age of five years.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors acknowledge Ms. Amee Amin for English language check of the paper.