Knowledge and practice of complementary feeding among mothers of the children aged group 6-24 months

INTRODUCTION

Complementary feeding refers to introducing an infant to foods other than breast milk, usually at six months of age.¹ WHO and UNICEF guidelines recommend exclusive breastfeeding for the first six months, followed by the introduction of complementary foods to meet increasing nutritional requirements.² Proper initiation of complementary feeding is essential, as deviations can lead to inadequate energy and nutrient intake, suboptimal growth, and increased susceptibility to infections.^3,4 Early or delayed introduction is associated with higher morbidity and nutritional deficiencies. In Nepal, under-five mortality was 39 per 1,000 live births in 2016, with approximately one million children affected by chronic malnutrition.⁵ Timely, safe, adequate, and frequent complementary feeding is crucial for optimal growth and development.⁶ Complementary foods bridge the nutritional gap between breast milk and the child’s needs, and inappropriate feeding practices contribute to malnutrition.⁷ Despite awareness, complementary feeding practices remain suboptimal.

NDHS 2011 reported that only 57% of mothers introduced complementary foods at six months, while early or delayed initiation persisted due to cultural practices, misconceptions about breast milk sufficiency, and ceremonial customs like “Pasni”.⁸ Global studies also report low compliance: in India, 7% of breastfed children aged 6–23 months met minimum acceptable diet criteria; in Nigeria, only 21%; and in Ethiopia, 4.2%.⁹

Maternal knowledge strongly influences complementary feeding practices. In Ethiopia, 95.6% of mothers knew the importance of complementary feeding, and 89.5% identified fruits and vegetables as suitable foods, though actual practices often lagged due to socio-cultural and economic factors.¹⁰ Similarly, in Nepal, many postnatal mothers had good knowledge, but early and delayed introduction remained prevalent.¹¹ Given these challenges, assessing maternal knowledge and practices regarding complementary feeding is crucial to improve child nutrition, guide interventions, and provide baseline data for future research.

Understanding existing practices can inform nutrition education programs and support better growth and development outcomes for children aged 6–24 months. The general objective of this study is to assess the knowledge and practice of complementary feeding among mothers of children aged 6–24 months in Mahalaxmi, Lalitpur. Specific objectives are to evaluate maternal knowledge and current complementary feeding practices.

The study addresses the following research questions: what is the level of maternal knowledge regarding complementary feeding, and what are the prevailing complementary feeding practices among mothers in Mahalaxmi, Lalitpur?.

METHODS

Study design and setting

A cross-sectional descriptive study was conducted to assess the knowledge and practices of complementary feeding among mothers of children aged 6–24 months. The study was carried out in Mahalaxmi Municipality, Lalitpur District, Nepal. Data collection was conducted over a five month period from January 2025 to May 2025 among mothers attending Primary Health Care (PHC) services.

Study population

The study population comprised mothers with children aged 6–24 months residing in Mahalaxmi Municipality and available at the time of data collection.

Sample size and sampling technique

The sample size was calculated using the Cochran formula, assuming a prevalence of adequate knowledge on complementary feeding of 19%, a 95% confidence level, and a 5% margin of error.¹² The calculated sample size was 237 mothers. Of these, 208 were successfully recruited and included in the study, resulting in a response rate of 87.8%. A non-probability purposive sampling technique was employed to select eligible participants who met the inclusion criteria.

Eligibility criteria

Inclusion criteria included mothers of children aged 6–24 months who were willing to participate and available during data collection. Exclusion criteria included mothers who declined consent, had severe mental illness, or were unable to respond to the questionnaire.

Data collection instrument

Data were collected using a semi-structured questionnaire developed based on study objectives, literature review, and expert consultation. The questionnaire was prepared in English and Nepali and consisted of two sections: socio-demographic characteristics and knowledge and practices related to complementary feeding.

Validity and reliability

Content validity of the instrument was ensured through expert review and consultation with the research guide. Reliability was assessed by pretesting the questionnaire on 10% of the sample in a similar setting (Bajrabarahi, Lalitpur). Necessary modifications were made based on pretest findings.

Data collection procedure

Permission for data collection was obtained from the concerned authorities. The researcher personally collected data after explaining the purpose of the study to participants. Written informed consent was obtained prior to data collection.

Confidentiality was maintained by assigning codes instead of personal identifiers. Completed questionnaires were collected on the same day, and the average time for completion was approximately 30 minutes.

Ethical considerations

Ethical approval was obtained from the National Health Research Council (NHRC), Nepal, prior to data collection. Participation was voluntary, and respondents were informed of their right to withdraw at any time without consequences. Privacy, anonymity, and confidentiality were maintained throughout the study, and collected information was used solely for research purposes.

Data analysis

Data were reviewed for completeness, coded, and entered into Statistical Package for Social Sciences (SPSS) software. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used to summarize the data. Results were presented in tabular form.

RESULTS

A total of 208 mothers participated in the study. The mean age of the respondents was 27.10±6.30 years.

Nearly half of the respondents (45.7%) belonged to the age group 17–25 years, followed by 40.9% in the 26–34 years age group, while 13.5% were aged 35–43 years. Regarding ethnicity, the majority of respondents were Janajati (68.8%), followed by Brahmin/Chhetri (19.7%) and Dalit (11.5%).

No respondents were from Madhesi or other ethnic groups. In terms of religion, more than half of the respondents were Hindu (57.2%), while 23.6% were Christian and 19.2% were Buddhist. More than half of the mothers (54.3%) had one child, while 29.3% had two children. A smaller proportion had three children (10.6%) and four children (5.8%). Concerning the age of the index child, 42.8% of the children were aged 19–24 months, followed by 31.3% in the 13–18 months age group and 26.0% in the 6–12 months age group.

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All respondents were literate (100%). Among them, 41.8% had attained secondary level education, 25.5% had primary level education, 22.1% could read and write only, and 10.6% had completed higher secondary level education. More than half of the respondents belonged to nuclear families (52%), while 48% were from joint families. In terms of gender, 55% of the children were female and 45% were male. With respect to occupation, 31.73% of the respondents were homemakers, followed by those engaged in agriculture (25.96%) and business (25.48%). Additionally, 10.58% were laborers, and 6.25% were government employees.

Respondents’ knowledge regarding complementary feeding and their sources of information. The majority of respondents (69.2%) correctly identified complementary feeding as introducing solid foods alongside continued breastfeeding. However, 22.1% perceived complementary feeding as replacing breastmilk with solid foods, while 8.7% believed it meant continuing exclusive breastfeeding, indicating gaps in knowledge among a notable proportion of mothers. Regarding sources of knowledge (multiple responses), family members were the most commonly reported source (42.2%), followed by Female Community Health Volunteers (FCHVs) (25.3%). Other sources included health service providers (11.5%), social media (8.1%), and relatives (8.1%), while fewer respondents cited neighbors (3.4%) and friends (1.4%) as sources of information. Concerning the understanding of exclusive breastfeeding, more than half of the respondents (57.2%) correctly defined it as feeding only breastmilk without any additional foods or liquids, whereas 42.8% incorrectly believed it involved feeding breastmilk along with complementary foods.

Majority 52.4% of respondents practiced exclusive breastfeeding up to six months, while 42.8% continued exclusive breastfeeding for more than six months. A small proportion (4.8%) reported exclusive breastfeeding for less than six months. Regarding the timing of introduction of complementary feeding, more than half of the respondents (52.4%) reported introducing complementary foods at any time as per perceived need. Nearly one-quarter (24.5%) introduced complementary feeding after six months, whereas 23.1% initiated complementary feeding before six months. With respect to continuation of breastfeeding along with complementary feeding, 47.6% of mothers continued breastfeeding for more than two years, while 33.2% continued up to two years. Smaller proportions continued breastfeeding up to six months (10.6%) and up to one year (8.7%). Over half of the respondents (52.4%) reported that complementary food should be given to a child up to two years of age, while 47.6% believed that complementary feeding should continue beyond two years. Regarding the consistency of complementary food, half of the respondents (50.5%) preferred liquid foods for their children. More than one-third (36.1%) reported using semi-solid foods, while 10.6% provided solid foods. A small proportion (2.9%) reported giving a mixture of both solid and liquid foods. In relation to the feeding environment, 41.3% of mothers reported feeding their child alone, whereas 36.1% fed their child with the support of entertainment. Only 22.6% reported feeding the child together with family members.

Regarding factors influencing the choice of complementary foods, the majority of respondents cited child preferences (30.9%) as the main consideration, followed by family tradition or cultural practices (25.6%). Other reasons included convenience or availability of food (17.6%), nutritional value (13.7%), and pediatrician recommendations (12.2%). When asked about the proper way of introducing complementary feeding, over half of the respondents (56.7%) correctly recognized its role in reducing iron deficiency anemia, while 41.5% believed it helps to improve mental development. A small proportion (1.8%) linked complementary feeding to prevention of stunting. Only 11.5% of mothers reported experiencing digestive issues in their child after introducing complementary foods, with stomach discomfort (83.3%) being the most common complaint, followed equally by constipation (8.3%) and diarrhea (8.3%).

Regarding the perception of the effect of complementary feeding on child digestion, most respondents (76.9%) remained neutral, while 5.8% agreed that it affects digestion and 17.3% disagreed. Most mothers (83.1%) reported providing homemade foods to their children, while 8.1% used marketed foods, and 8.9% provided a combination of both. In terms of the types of food fed, the majority (81.7%) offered Vitamin A–rich fruits and vegetables, whereas 18.3% fed primarily grains. Regarding continuation of breastfeeding after initiating complementary feeding, 63.9% of mothers reported that they continued breastfeeding, while 36.1% stopped. Among those who continued, 45.1% breastfed on demand, 29.3% reduced breastfeeding frequency during the daytime, 19.5% continued regular and frequent breastfeeding, and 6.0% refrained from breastfeeding for 2–3 hours before a meal. All respondents (100%) reported washing their hands before feeding their child, indicating good hygiene practices. Regarding types of complementary food, the most commonly used items were Ceralac (28.3%) and Lito and Jaulo (33.4%), followed by fruits and vegetables (19.3%) and dal with rice (19.1%). In terms of feeding frequency, 30.8% of mothers fed their child more than three times a day, 26.5% fed thrice daily, 21.6% fed twice daily, and 21.1% fed once daily. While preparing complementary food, the majority (92.3%) maintained a thick consistency, whereas a small proportion (7.7%) prepared food with a thin consistency. Most mothers (72.6%) reported exclusively breastfeeding their child for more than six months, while 26.4% practiced exclusive breastfeeding up to six months, and only 1.0% breastfed for less than six months. Among mothers who introduced complementary feeding before six months, the main reasons were insufficient breastmilk (62.0%), followed by cultural practices (33.2%), child not gaining weight (2.9%), and mother’s unwillingness to breastfeed (1.9%).

For those who started complementary feeding after six months, the reasons included meeting nutritional needs (63.0%), supporting growth and development (46.6%), and advice from elders (4.6%). Nearly half of the respondents (45.7%) reported child’s refusal to eat as a challenge when introducing complementary foods. Other challenges included digestive problems (29.3%), uncertainty about food choice (24.0%), and allergic reactions (1.0%). Regarding reasons for delayed introduction of complementary feeding, vomiting (35.1%) and the perception that milk alone was sufficient (28.4%) were the most common factors. Other reasons included child’s refusal to accept other foods (25.0%) and advice from elders (11.5%). When the child was ill, the majority of mothers (61.1%) reported feeding less than usual, 29.3% continued feeding as usual, and only 9.6% fed more than usual.

DISCUSSION

This descriptive cross-sectional study assessed the knowledge and practices of complementary feeding among mothers of children aged 6–24 months. The findings highlight important socio-demographic characteristics, maternal knowledge levels, feeding practices, and challenges, which are largely comparable with findings from similar studies conducted in Nepal and other low- and middle-income settings.

The majority of mothers in the present study were young, with nearly half aged 17–25 years, which is consistent with previous studies reporting that complementary feeding practices are commonly managed by younger mothers.¹³ The predominance of Janajati ethnicity and the nearly equal distribution of male and female children align with earlier research conducted in similar communities.¹³ These similarities suggest that the study population is representative of mothers accessing primary health care services in peri-urban settings of Nepal.

Family structure and maternal education play a critical role in child feeding practices. In this study, more than half of the mothers lived in joint families, and all respondents were literate, with the majority having secondary-level education. Comparable findings were reported in earlier studies where joint family systems were common and maternal literacy levels were high.¹⁴ Living in joint families may positively influence feeding practices through shared caregiving and knowledge exchange; however, it may also contribute to traditional beliefs that affect the timing and type of complementary feeding. The age distribution of children in this study showed a higher proportion of children aged 19–24 months, similar to findings reported in other studies where older infants constituted a significant share of the sample.¹⁵ This distribution is advantageous for assessing sustained complementary feeding practices beyond the initiation phase.

Regarding knowledge of complementary feeding, over two-thirds of mothers correctly defined complementary feeding as the introduction of solid or semi-solid foods alongside breastmilk. This level of awareness is higher than that reported in some previous studies, where just over half of mothers had adequate knowledge.¹⁶ Family members were identified as the primary source of information, followed by Female Community Health Volunteers (FCHVs) and health care providers, which is consistent with earlier findings emphasizing the influence of family and community-based health workers on maternal practices.¹⁶ This highlights the continued importance of interpersonal communication over mass media in shaping infant feeding behaviors.

Breastfeeding practices in the present study were generally favorable, with a majority of mothers continuing breastfeeding after the initiation of complementary feeding. Although exclusive breastfeeding up to six months was reported by only a quarter of respondents, continued breastfeeding beyond six months was common, reflecting partial adherence to WHO recommendations. Similar breastfeeding continuation patterns have been documented in other studies conducted in Nepal.^16,17

Complementary feeding practices revealed that most mothers relied on homemade foods, which is consistent with findings from comparable studies and aligns with recommended practices for young child nutrition. The high use of vitamin A–rich fruits and vegetables suggest good dietary diversity; however, the low inclusion of grains and other food groups indicates potential gaps in achieving a balanced diet. Feeding frequency varied, with only about one-third of mothers meeting the recommended feeding frequency, a finding echoed in other studies where inadequate meal frequency remained a concern.¹⁶

Encouragingly, most mothers reported maintaining thick food consistency and universally practiced handwashing before feeding, indicating good hygiene awareness. Similarly high levels of hygiene practice have been reported in studies conducted among health service–utilizing populations.¹⁴

Despite overall good knowledge and practices, several challenges were identified. Child refusal to eat and digestive problems were common barriers, consistent with previous research highlighting feeding difficulties as a major concern during infancy.¹⁶ Early introduction of complementary foods was mainly attributed to perceived insufficient breastmilk and cultural practices, while delayed introduction was influenced by beliefs about nutritional needs and advice from elders. These findings underscore the persistent role of cultural norms and misconceptions in feeding decisions.

While many mothers recognized the role of complementary feeding in reducing iron deficiency anemia and supporting mental development, very few associated it with stunting prevention. This gap in understanding has also been noted in earlier studies and indicates a need for focused nutrition education addressing long-term growth outcomes.¹⁷

Overall, although maternal literacy and basic knowledge of complementary feeding were relatively high, gaps remain in the timing, frequency, dietary diversity, and management of feeding challenges, particularly during child illness. These findings emphasize the need for targeted behavior change communication, regular counseling by health workers, and strengthened involvement of FCHVs to promote optimal complementary feeding practices in line with WHO recommendations.^16,17

This study has several limitations that should be considered when interpreting the findings. It was limited to mothers of children aged 6–24 months, which may limit the applicability of the results to other age groups. Additionally, as the study was conducted in a single geographic area, the generalizability of the findings to other settings may be limited. Furthermore, the study was self-funded, which may have constrained the scope and resources available for data collection and analysis.

CONCLUSION

The study revealed that while maternal literacy and awareness regarding complementary feeding in Mahalaxmi, Lalitpur, were generally high, actual feeding practices were inconsistent with recommended guidelines. Most mothers correctly understood the concept of complementary feeding and the importance of continued breastfeeding, yet many introduced complementary foods either earlier or later than six months, often influenced by perceived insufficient breastmilk, cultural practices, or child preferences. Homemade foods, particularly Vitamin A–rich fruits and vegetables, were commonly provided, and hygiene practices were excellent. However, challenges such as child refusal, digestive issues, and uncertainty about food choices affected feeding practices. The findings highlight the need for targeted health education and awareness programs by health workers and Female Community Health Volunteers to reinforce proper timing, frequency, consistency, and responsive feeding practices, thereby supporting optimal growth and development in children aged 6–24 months.

ACKNOWLEDGEMENTS

The Authors would like to express their sincere appreciation to the primary health care facilities of Mahalaxmi Municipality, Lalitpur District, Nepal, for their support during the data collection process, also deeply grateful to all mothers of children aged 6–24 months who participated in this cross-sectional study and generously shared their time and experiences and acknowledge the valuable assistance of local health personnel who facilitated access to participants throughout the study period. Artificial intelligence tools were used to enhance the readability and clarity of the manuscript; however, the Authors take responsibility for its content.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the National Health Research Council (NHRC), Nepal

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