Assessment of complementary feeding knowledge and practices of mothers registered at Anganwadi centers of Jaipur

INTRODUCTION

Malnutrition occurs during the most critical period of development, i.e., six months to 24 months of birth with long-term implications on physical and mental development that are difficult to address later.¹

According to World Health Organization, 45 per cent of child deaths occur due to undernutrition. Infant and young child feeding (IYCF) is essential for growth and their survival.² Optimal nutrition during the first two years of child reduces morbidity and mortality, lowers the risk of chronic disease, and promotes overall development.^3-5 In India, delayed introduction of supplemental foods is directly associated with stunting and severe stunting in 6-8-month-old infants.⁶

The first 1000 days of a child from conception to 2 years of age is also known as the "window of opportunity" because this is a crucial period for the development of a healthy individual.⁷

After six months, infants need both breast milk and complementary foods to grow strong and develop fully.⁸ Inappropriate or delayed complementary food introduction can stunt an infant's growth.² Breast milk alone cannot provide all the nourishment needed by infants older than six months.^9,10 There is emerging evidence that inadequate nutrition impacts the learning ability and productivity. Stunted growth in children indicates a lack of nutrients for linear growth and the growth of critical organs, including the brain.¹¹

As per NFHS-5 (Table 1), total number of children under five years of age in India, 19.3 per cent are wasted (acute malnutrition), 35.5 per cent are stunted (chronic malnutrition), 32.1 per cent are underweight, and 67.1 per cent are anemic, mainly due to improper timing of initiation of complementary foods.^12,13

Considering the importance of timely introduction of complementary food, one of the pre-requisites is to assess the existing knowledge and practices related to complementary feeding.¹⁴ There is a need to educate mothers for using locally available foods for complementary feeding and educating them with the benefits of breastfeeding for mother and child both as long and short term healthy, economic and environmental benefits.^15,16

Therefore, the present study was aimed to conduct on assessment of knowledge and practices of the mothers registered at AWCs of Jaipur.

METHODS

Study design

This exploratory study was conducted between June 2016 and June 2017 on mothers registered on Anganwadi centres of Jagatpura, Jaipur, Rajasthan. All the mothers of children registered at Anganwadi centres were selected as the sample to assess knowledge and practicesregarding complementary feeding. Questionnaire was prepared and questions were asked orally and recorded based on the cooperation provided by the respondents (mothers).

The means were calculated and presented in per cent values as results. Ethical approval is not required in the present study as no feeding trials were done.

Inclusion and exclusion criteria

The inclusion criteria in this study were all the mothers of children aged from six months to two years registered at Anganwadi centres. The exclusion criteria were the mothers who were not registered at Anganwadi centres and incomplete questionnaires in one or more parameters.

The study was carried out in the following phases

Phase I: Selection of AWCs

Jagatpura area was selected which is dominated by urban slums. Out of 39 AWCs, 10 centers were selected on the basis of average functioning of AWCs (Source: ICDS office, Jaipur).

Phase II: Selection of children

As per the ICDS sources, on an average 10-12 children aged 6-24 months at selected 10 AWCs formed the subject group. Thus, a total of 100 children were further divided into two groups on the basis of age; children aged 6 months to 12 months and children aged 1-2 years. Equal numbers of children were taken from each group, i.e., 50+50.

Phase III: General information of the children with focus on supplementary nutrition

Literacy status and occupation of the parents, number of children collection of supplementary food given at AWC, amount and form in which this supplementary food is given to the child.

Phase IV: Assessment of knowledge of mothers regarding complementary feeding

Oral questionnaire method was used for collecting the information. The questions were probed to all the mothers of 100 children and information/responses were recorded on the questionnaire itself.

Phase V: Assessment of complementary feeding practices

On the basis of the willingness of the mothers to co-operate in the assessment and also permission to enter the house and kitchen, mothers of children aged 6 months to 2 years were selected. 10 children from 6-12 months and 10 from 1-2 years were the final subjects for assessment of knowledge on complementary feeding practices.

A checklist was prepared on the issues related to complementary feeding. This checklist included questions plus things to be observed. Personal visits were made to the houses at the time of preparation and feeding of one meal to be fed to the children.

Phase VI: Identification of gaps in knowledge and practices

The data/information collected was analyzed and gaps in knowledge and practices was enlisted.

Phase VII: Formulation of sample menu

A sample was prepared based on the gaps identified in complementary foods, foods available at home and supplementary nutrition (SN) given at AWC.

RESULTS

Literacy status and occupation of parents of selected children (n=100)

87% of the mothers were housewives and 94% of mothers found literate. It clearly shows that these are potential mothers who can take nutritional care of the children (Figure 1 and 2).

Distribution of 6-24 months children registered at AWC and receiving the SN at AWC (n=100)

Only 49 per cent of the registered children in age group 6-12 months and 63 per cent were from 12-24 months age group collecting SN. However, the percentage SN has increased in the age group of 1-2 years (Table 2).

Reasons for receiving SN

Awareness about the benefits of SN communicated by Accredited Social Health Activist (ASHA) in Arogya Meeting and easy access to AWC SN. The mothers collecting SN (Panjiri) feeding their children in directly by mixing it with water or milk, as halwa and mixing Panjiri with wheat flour for making Chapattis. Reasons reported by those mothers who were not collecting the SN includes dislike for the Panjiri taste and mothers were not sensitized on regular collection of weekly rations (Table 2). In addition, households staying as tenants are not provided with SN and self-help groups does not prepare beyond a fixed number of packets. Also due to the family restrictions mothers were not allowed to go out from the house.

Assessment of knowledge of mothers regarding complementary feeding

All the mothers included in the study agreed that due to increasing age in children, introduction of solid foods is essential. 82% mothers reported that hunger gets increased and breast milk is not sufficient after the age of 6 months. 62% of the mothers were knowledgeable about introduction of complementary feeding. 38% of the mothers were not knowledgeable about introduction of complementary feeding. 80% of the mothers were knowledgeable that breastfeeding should be continued up to 2yrs. 93% of the mothers were giving market milk (Saras) to the children. 42% of the mothers disagreed that there is a need for community support in feeding of children between 6-24 months. 80% of the mothers were giving home based cooked food. 88% of the mothers stopped giving semisolid foods during illness. 78% of the mothers agreed that food should be served in separate plate to the children (Table 2).

Assessment of current complementary feeding practices and gaps in knowledge

These were assessed by making personal home visits and with the help of a checklist. Ten children from each age group, 6-12 and 12-24 months, were selected. The information was noted based on the observations made while at home and with the help of the checklist.

Sample menu

Menu plan taking care of all the requirements was given to mothers of 6-12 months children (recommendations with at least 2 times breastfeed in a day) and 12-24 months children taking care of all the important foods rich in macro and micronutrients. The food items which are locally available and low in cost were suggested.

Child appetite

In the present study the findings reveal that the mothers are not increasing the frequency and amount of food and not including the food from the different food groups.

Care giver/mother behaviors

In the present study it was observed that mothers were not sensitized about the collection and feeding of SN given at AWC. Though the mothers gave homemade mashed foods to the children but the type, frequency and amount found to be inadequate, the mothers agreed that food served to the child in separate plate. To ensure adequate amount of food but was not practiced.

Characteristics of the diet

During the home visits made by the researcher, it was observed that the mothers were not cleared with the consistency of the feed/diet.

DISCUSSION

In the present study, majority (94%) mothers of children aged 6 months to 2 years were found literate which indicates that the mothers could understand and implement the appropriate complementary feeding practices. Hence, timely messages on complementary nutrition by the frontline functionaries can definitely help in meeting the adequacy of nutrition in children between 6-24 months.^17,18 Complementary feeding after the age of six months plays an important role in building the productivity in later years of children.¹⁹ In the present study, it was found that less than 50% mothers of children aged 6-12 months were collecting the SN given by Anganwadi centers. It reflects that there is a strong need for focusing on timely introduction of SN at 6 months and increasing the intake as the age increases. The findings show those 6-12 months is a critical period for growth and hence, adequate nutrition becomes a prime factor.^20,21 Mothers were collecting the SN due to the availability and easy mixing with other flours for making food for children. Those who were not collecting reported disliking of the taste. Mothers agreed (82%) that the introduction of complementary food is required for increasing growth. Similar study reported that infants need good nutrition during growing years.^22,23

According to the above findings there is a strong need for timely introduction of complementary foods, nutrition counseling during illness and making the mothers aware that even the community support is required for the nutrition of the children (AWC services). Hence, emphasis should be more on Frequency, Adequacy, Density and Utilization (FADU).^24,25 Further, the recently launched programme i.e., diarrheal management using ORS and zinc should be strengthened to increase the appetite of the child. The mothers should be motivated for responsive feeding and to provide adequate time and resources for feeding of the child. Appropriate messages on increasing the caloric density of the food, hygiene and cleanliness, proper selection of foods, consistency of the food and techniques of the complementary feeding should be communicated to the mothers.²⁶ To conclude messages based on guiding principles on complementary feeding should be formulated and communicated to the mothers.²⁷

The limitations of the study include the behaviour towards the complementary feeding practices followed by mothers which were already in the system but not followed properly. Hence more focus should be on the sensitization regarding the complementary feeding among not only the mothers but also to the father and other family members so that the problem of malnutrition could be tackled.

CONCLUSION

Inappropriate feeding practices are a leading cause of childhood malnutrition. Children who are not breastfed are more likely to have infections, grow slower, and die by the age of one month approximately six times as often as children who receive at least some breast milk. When breastfeeding alone is no longer sufficient to meet all nutritional needs, newborns enter a critical time of supplemental feeding from six months onwards, during which they gradually transition to consuming family foods.

Child hunger, caregiver/mother behavior, and diet features are three independent factors that are likely to interact to determine complementary food consumption.

ACKNOWLEDGEMENTS

Head, Department of Home Science, University of Rajasthan, Jaipur is duly acknowledged for lab facilities.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Schwarzenberg SJ, Georgieff MK, Daniels S, Corkins M, Golden NH, Kim JH, et al. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics. 2018;141(2).
2. 2. World Health Organization (WHO). (2021). Infant and young child feeding: Factsheet. Available at: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding.
3. 3. Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta‐analysis. Actapaediatrica. 2015;104:3-13.
4. 4. Wallace TC, Bailey RL, Blumberg JB, Burton-Freeman B, Chen CO, Crowe-White KM, et al. Fruits, vegetables, and health: A comprehensive narrative, umbrella review of the science and recommendations for enhanced public policy to improve intake. Critical reviews in food science and nutrition. 2020;60(13):2174-211.
5. 5. Pecora F, Persico F, Argentiero A, Neglia C, Esposito S. The role of micronutrients in support of the immune response against viral infections. Nutrients. 2020;12(10):3198.
6. 6. Dhami MV, Ogbo FA, Osuagwu UL, Ugboma Z, Agho KE. Stunting and severe stunting among infants in India: the role of delayed introduction of complementary foods and community and household factors. Global Health Action. 2019;12(1):1638020.
7. 7. Beluska-Turkan K, Korczak R, Hartell B, Moskal K, Maukonen J, et al. Nutritional gaps and supplementation in the first 1000 days. Nutrients. 2019;11(12):2891.
8. 8. Binns C, Lee MK, Yun Low W, Baker P, Bulgiba A, Dahlui M, et al. Guidelines for complementary feeding of infants in the Asia Pacific region: APACPH Public Health Nutrition Group. Asia Pacific J Public Health. 2020;32(4):179-87.
9. 9. Mӧrelius E, Kling K, Haraldsson E, Alehagen S. You can't flight, you need to fight - a qualitative study of mothers' experiences of feeding extremely preterm infants. J Clin Nurs. 2020;29(13-14):2420-8.
10. 10. Sánchez C, Franco L, Regal P, Lamas A, Cepeda A, Fente C. Breast milk: a source of functional compounds with potential application in nutrition and therapy. Nutrients. 2021;13(3):1026.
11. 11. Roberts M, Tolar-Peterson T, Reynolds A, Wall C, Reeder N, Mendez RG. The effects of nutritional interventions on the cognitive development of preschool-age children: a systematic review. Nutrients. 2022;14(3):532.
12. 12. National Family Health Survey (NFHS-5) 2019–2021 (2021). India Fact Sheet. International Institute of Population Sciences, Ministry of Health and Family Welfare, Government of India. Available at: http://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf
13. 13. National Family Health Survey (NFHS-5) 2019–2021 (2021). State Fact Sheet: Rajasthan. International Institute of Population Sciences, Ministry of Health and Family Welfare, Government of India. Available at: http://rchiips.org/nfhs/NFHS-5_FCTS/Rajasthan.pdf
14. 14. Kittisakmontri K, Fewtrell M, Roekworachai K, Phanpong C, Lanigan J. Complementary feeding: Attitudes, knowledge and practices of urban families in northern Thailand. Nutrition Dietetics. 2019;76(1):57-66.
15. 15. Tampah-Naah AM, Kumi-Kyereme A, Amo-Adjei J. Maternal challenges of exclusive breastfeeding and complementary feeding in Ghana. PloS one. 2019;14(5):e0215285.
16. 16. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491-504.
17. 17. World Health Organization. (2008). Strengthening action to improve feeding of infants and young children 6-23 months of age in nutrition and child health programmes: report of proceedings, Geneva. Available at: https://apps.who.int/iris/bitstream/handle/10665/44034/9789241597890_eng.pdf?sequence=1&isAllowed=y.
18. 18. Chandorkar S, Miyawala T. Assessing gaps in Infant and Young Child Feeding (IYCF) practices and capacity building of functionaries and beneficiaries of Integrated Child Development Services (ICDS) for improved outcomes. J Nutrition Res. 2014;2(1):26-31.
19. 19. Ali AI, Verma A, Paul V. Assessment of prevailing supplementary and weaning practices in the selected area of Allahabad. J Pharmacog Phytochem. 2018;7(5):180-6.
20. 20. Ogunlesi TA, Ayeni VA, Adekanmbi AF, Fetuga BM. Determinants of timely initiation of complementary feeding among children aged 6 24 months in Sagamu, Nigeria. Nigerian J Clin Pract. 2014;17(6):785-90.
21. 21. Fewtrell M, Bronsky J, Campoy C, Domellöf M, Embleton N, Mis NF, et al. Complementary feeding: a position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. J Pediatric Gastroenterol Nutrition. 2017;64(1):119-32.
22. 22. Rao S, Swathi PM, Unnikrishnan B, Hegde A. Study of complementary feeding practices among mothers of children aged six months to two years - a study from coastal south India. Australasian Medical J. 2011;4(5):252.
23. 23. Fegan S, Bassett E, Peng Y, O’Connor KS. Adherence to complementary feeding recommendations for infants and implications for public health. Public Health Nutrition. 2016;19(4):638-49.
24. 24. Senarath U, Dibley MJ. Complementary feeding practices in South Asia: analyses of recent national survey data by the South Asia Infant Feeding Research Network. Maternal Child Nutr. 2012;8:5-10.
25. 25. Manikam L, Prasad A, Dharmaratnam A, Moen C, Robinson A, Light A, et al. Systematic review of infant and young child complementary feeding practices in South Asian families: the India perspective. Public Health Nutr. 2018;21(4):637-54.
26. 26. Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P, Banapurmath CR, et al. Infant and young child feeding guidelines, 2016. Indian Pediatr. 2016;53(8):703-13.
27. 27. Vazir S, Engle P, Balakrishna N, Griffiths PL, Johnson SL, Creed‐Kanashiro H, et al. Cluster‐randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers. Maternal Child Nutr. 2013;9(1):99-117.