Assessment Of Complementary Feeding In Enhancing Growth Of Infants 6-12 Months Among Nursing Mothers Attending Child Welfare Clinic

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Assessment Of Complementary Feeding In Enhancing Growth Of Infants 6-12 Months Among Nursing Mothers Attending Child Welfare Clinic


Abstract


Adequate nutrition during the infancy and early childhood (6-12 months) is essential to ensure the growth, development and overall health of children to their full potential. Complementary feeding is the process starting when breast milk alone or infant formula alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other food and liquids are needed, along with breast milk or a breast-milk substitute. This study aimed at an assessment of complementary feeding in enhancing growth of infants 6-12 months among nursing mothers. The study consisted of interviewing 90 participants who are mothers of children of 6 to 12 months of age registered at “Kogi State University Teaching Hospital” using a semi-structured questionnaire. The study revealed that a high percentage of the mothers were aware of the appropriate duration of exclusive breastfeeding (93%) and complementary feeding (96%). However, only 58% of the mothers correctly practiced exclusive breastfeeding and 63% initiated complementary feeding at the recommended time. Hence there was a large gap between the knowledge of mothers and actual practice which was influenced by a number of factors. Socioeconomic factors that significantly affected both the level of knowledge and practices include the type of family, education level of the mother and number of children in the family. Factors such as lactation failure and working mothers largely contributed to early initiation of complementary feeding. Flexible working hours, increased guidance and support by the health care providers and better methods of information dissemination needs to be established to improve the current situation.


Table of Content


Chapter One:

Introduction

  • 1.1 Background to the Study
  • 1.2 Problem Statement
  • 1.3 Purpose of the Study
  • 1.4 Objectives of the Study
  • 1.5 Research Questions
  • 1.6 Test of Hypothesis
  • 1.7 Significance of the Study
  • 1.8 Scope of the Study
  • 1.9 Definition of Terms
  • 1.10 Organization of the Study

Chapter Two:

Literature Review

  • 2.1 Conceptual Review
  • 2.2 Empirical Review
  • 2.3 Theoretical Review
  • 2.4 Summary of Literature Review

Chapter Three:

Research Methodology

  • 3.1 Research Design
  • 3.2 Population and Sample
  • 3.3 Sample size Determination
  • 3.4 Sampling Frame and Technique
  • 3.5 Instrumentation
  • 3.6 Validity and Reliability of the Research
  • 3.7 Data collection procedure
  • 3.8 Framework for Data Analysis
  • 3.9 Ethical Consideration

Chapter Four:

Data Analysis and Result Presentation

  • 4.1 Presentation of Results
  • 4.7 Hypotheses Testing

Chapter Five:

Discussion and Conclusion

  • 5.1 Summary
  • 5.2 Discussions
  • 5.3 Implications
  • 5.4 Limitations of the study
  • 5.5 Recommendations
  • REFERENCES
  • APPENDIX 

Chapter One


Introduction

1.1 Background to the Study

Optimal Infant and Young Child Feeding (IYCF) practices rank among the most effective interventions to improve child health. Adequate nutrition during the infancy and early childhood which is referred to the first 2 years of a child is particularly essential to ensure the growth, development and overall health of children to their full potential. Inadequate nutrition during this period could increase the overall morbidity and mortality, and the risk of chronic illnesses (World Health Organization, 2009).

To improve the nutritional status, growth and development of infants and young children, WHO and UNICEF jointly developed a global strategy for infant and young child feeding in 2002. It recommends that every child should be exclusively breastfed for 6 months (180 days) followed by nutritionally adequate and safe Complementary Feeding (CF) starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond. Therefore, in IYCF, adequate and proper CF practices are equally important as breastfeeding, for the child, after 6 months of age (WHO, 2003).

WHO defines complementary feeding as “the process starting when breast milk alone or infant formula alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other food and liquids are needed, along with breast milk or a breast-milk substitute” (WHO, 2015).

The transition period from exclusive breastfeeding (EBF) to family food typically covers the period from 6 to 12 months of age. It is called as the “critical window” for the promotion of optimal growth, health and behavioral developments (WHO, 2015). During this period of time, infants and young children are at an increased risk of malnutrition. From six months onwards, breast milk alone is no longer adequate to meet all their nutritional requirements and CF should be initiated (WHO, 2015).

Malnutrition is reflected as a continuous cycle. A malnourished girl child faces greater probabilities of giving birth to a malnourished, low birth weight infant when she grows up. Furthermore, poor feeding practices could cause immediate consequences and long term consequences. The immediate consequences of poor nutrition during these formative period results in significant morbidity, mortality, delayed mental health and motor development. In the long term basis, nutritional defects could lead to impairment of intellectual performances, work capacity, reproductive outcomes and overall health during adulthood (WHO, 2005).

The convention on the rights of the child (as cited in WHO, 2015) states that, each and every child has the right to receive good nutrition. Recent records of WHO shows that, 45% of child deaths are associated with undernutrition. Globally in 2012, 162 million children who are under 5 years of age are estimated to be stunted, and 51 million have low weight- for height and 42 million children were overweight or obese. Worldwide, only about 36% of infants 0 to 6 months old are exclusively breastfed. It gives evidence that many infants and children do not receive optimal feeding (WHO, 2015).

According to WHO statistics 2015, globally, the number of deaths of children under-5 years of age reduced by 12.7 million to 6.3 million, from 1990 to 2013. It is estimated that, 45% of these deaths are due to undernutrition which includes fetal growth restriction, stunting, wasting and deficiencies of vitamin A and zinc, along with suboptimal breastfeeding (WHO, 2015).

The Rate of malnutrition is still high in most of the developing countries. Researches have shown that in developing countries, one-third of children less than five years of age are stunted (low height-for-age), and a large proportion of children are also deficient in one or more micronutrients (UNICEF, 2005). Recent data indicates that just over half of 6-9 month olds are breastfed and given adequate complementary food and only 39 per cent of 20-23 month olds are provided with continued breastfeeding (WHO, 2015). The proportion of underweight children in developing countries has declined from 28% to 17% between 1990 and 2013. This rate of progress is close to the rate required to meet the MDG target, however improvements have been unevenly distributed between and within different regions.


1.2 Problem Statement

Adequate nutrition during infancy and early childhood is the foremost fundamental for each child in order to bring about the developments to full human potential. Lack of knowledge and proper feeding practices contribute to higher childhood morbidity and mortality. Poor infant feeding practices is one of the principal proximate causes of malnutrition during the first two years of life (WHO, 2005). Martoral et al., in 1964 (as cited in WHO, 2013) agreed that, it is very difficult to reverse the stunting that has occurred earlier, after the child reaches 2 years of age. Hence, it is essential to ensure that the mothers or caregivers are provided with appropriate guidance regarding optimal feeding of the infants and young children during the period of 6-12 months.

Nigeria under-five mortality rate has declined by less than half, dropping from 32.5 to 17.5 deaths per 1,000 live births between 1994 and 2009. According to the published statistics of Health Protection Agency; (HPA, 2014), in Nigeria there are 17.3% of under weighed, 18.9% with stunted growth rate and 10% of wasted children among less than 5 years of age population. Moreover, there are children with vitamin A deficiency rate of 5.1% and iodine deficiency of 0.7%. It is notified that, these were the data of the demographic health survey that was conducted in 2009.

Knowledge on infants and young children feeding Practices (IYCP) are crucial for undertaking or improving health and nutrition programme in a country. To the best of the knowledge, no studies have been undertaken recently, on CF practices among the mothers in Nigeria. Hence, in this study CF practices of 6-12 month old children from Male’ will be assessed and the knowledge gaps among their mothers will be identified.


1.3 Purpose of the Study

To make an assessment of complementary feeding in enhancing growth of infants 6-12 months among nursing mothers attending child welfare clinic.


1.4 Objectives of the Study

  1. To identify the socio-demographic and socio-economic characteristics of the mothers of 6-12 months aged children
  2. To assess the knowledge of mothers of 6-12 months aged children with regard to correct exclusive breastfeeding and CF practices.
  3. To evaluate the practices of exclusive breastfeeding and CF in terms of quality, quantity and timing of CF for infants and young children of aged 6-12 months
  4. To determine the factors influencing proper exclusive breastfeeding and CF practices by the mothers of 6 to 12 months’ children’

1.5 Research Questions

  1. What is the scope of knowledge on exclusive breastfeeding and CF practices among mothers of children aged 6-12 months?
  2. What are the exclusive breastfeeding and CF practices implemented by mothers of children aged 6-12 months?
  3. What are the factors influencing exclusive breastfeeding and CF practices among mothers of children age 6-12 months?

1.6 Test of Hypothesis

  • H0 there is no significant relationship between complementary feeding and growth of infants
  • H1 there is significant relationship between complementary feeding and growth of infants

1.7 Significance of the Study

The findings of this study will be useful for all the health planners, health policy makers among governmental and non-governmental organizations to improve the feeding practices of the mothers, of infant and young child feeding, which would have impact on overall health of infants and young children.

Moreover, this study will help planners to identify the knowledge gaps to strengthen the actions to be taken to improve feeding practices of infants and young children of 6-12 months. It will help plan efforts for creating awareness and increase commitment of the government sectors, national organizations and other professional group for achieving optimal feeding practices for infants and young children. It would also be a great contribution for the health professionals to improve the quality of counselling for mothers and caregivers.


1.8 Scope of the Study

This cross-sectional descriptive study was carried out within the registered population of mothers of children between the ages 6-12 months of age in “Kogi State University Teaching Hospital”, which is amain institute in Nigeria for child health’. Hence, the study may not be magnified to the whole population of the country.
There might be other factors that can be addressed in the topic. Only major were taken into consideration.


1.9 Definition of terms

Exclusive Breastfeeding:

The infant receives no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines)

Infant and Young Child Feeding Practice:

It includes the following practices: early initiation of breastfeeding, colostrum feeding, use of bottle for feeding, prelacteal feeding, duration of exclusive breastfeeding, introduction of CF, meal frequency, use of oil/ghee in preparing child’s food and feeding practice of diverse food.

Complementary Feeding:

It included feeding breast milk (including milk expressed or from a wet nurse) and solid and semi-solid food. It allowed any food or liquid including non-human milk and formula feeding for the children 6-12 months of age. It did not include the non-breast feed children.

Minimum Dietary Diversity:

Proportion of children 6–23 months of age who receive food from 4 or more food groups Children 6–23 months of age.

Meal Frequency:

It was defined as the number of times the child was fed as per the age requirement in addition to the breast-feeding per day.


1.10 Organization of the Study

The study is organized into five chapters.

  • Chapter one covers; background to the study, statement of the problem, general objective of the study, specific objectives of the study, research hypotheses, significance of the study, limitation of the study, delimitations of the study, operational definition of terms and organization of the study.
  • Chapter two covers review of related literature.
  • Chapter Three covers research methodology which includes: introduction, research design, target population, sampling techniques and sample size, data collection instruments, validity and reliability of research instruments, data collecting procedures, data analysis techniques and ethical considerations.
  • Chapter four covers research results of the study.
  • Chapter five covers discussions and interpretations of research findings.

Chapter Five


Summary, Conclusion and Recommendation

5.1 Summary of Main Findings

  1. Most of the respondents were young below the age of 32, with their first child and with higher than primary education with the majority of them being unemployed.
  2. In the study, most of the respondents (84%) were aware that the child should be initiated with BF within one hour after the delivery. However, there were respondents who stated that child should be initiated with breast milk within 2 to 3 hours after the delivery.
  3. It is found that, 93% of the total respondents were aware of the appropriate duration of EBF while 96% of the total respondents were aware of the timing of initiation of CF.
  4. The study revealed that, most of the respondents (81%) introduced breast milk as the first feed for their child. EBF was established by 59% of the total respondents.
  5. The correct timing of initiation of CF was established by 62% of the respondents. Of the total, 36% of them had initiated it earlier than the recommended time. Earlier initiation was reported by most of the respondents as the child was not BF properly.
  6. Minimum meal frequency was achieved by most of the respondents (94%). However, almost half of the respondents have not provided the minimum dietary diversity for their children.
  7. When looked on to the socio-economic and socio demographic factors in relation to the feeding practices, it is noted that the number of children, type of family and education level of mother were the main factors that were significantly related to CF practices.
  8. In the present study, out of all the total factors, type of family, education level and number of children in the family, these three were significant factors related to the amount of knowledge that the respondents were having.
  9. Of all the respondents, 93% have the knowledge of the correct duration of EBF while only 58% of those are practicing it. Out of the total respondents 96% were aware of the timing of initiation of CF; however, only 63% of them had established it at the recommended time.

5.2 Discussions

This study was conducted with 90 mothers of children aged 6-12 months to assess the knowledge of mothers regarding CF, to evaluate the practices of CF in terms of quantity, quality and timing and to determine the major factors influencing these practices and knowledge.

In the current study, 41% of children were below 1 year of age, 38% were at the age group 13- 18 months and 20% were 19- 24 months of age. This age distribution seemed satisfactory as all the age groups were involved in the study. The gender distribution of male and female were only one child as it consists of the most common reproductive age group in Nigeria. The most common child bearing age group was recorded last in 2006, which was found to be 19- 25 years (Ministry of Health and Gender, 2014).

The study revealed that most of the respondents (Mothers) knew the duration of EBF (EBF) and timing of initiation of CF. However, the ideal duration and timings being followed by them were found to be low. It is found that, majority of the total respondents (93%) had the knowledge on duration of EBF but only, 58% of those are practicing it. This means 35% of the respondents who are aware of the proper knowledge have not practiced in the recommended manner. This is similar to the finding of the study conducted in Kanti Children’s Hospital, Nepal, with 1100 mothers where only a limited number of mothers practice exclusive breastfeeding although most are aware about the requirement. It revealed that 87% percent of mothers had knowledge about the duration of EBF but only 33% practiced it (Chapagain, 2015).

It was observed in the study that 93% of the respondents have knowledge on duration of EBF and the remaining 7% were not aware of the correct duration. About half, 54% of the mothers stated that the child should be continued with BF up to 2 years or beyond. A study carried out in Kahawa West Public Health Centre among the randomly sampled 286 mothers and their children showed over 90% of the mothers had high knowledge on exclusive breastfeeding for the first 6 months and 77% of the mothers testified that infants and children should be breastfed for two years and beyond (Mueni, 2014). UNICEF and WHO recommendations specify that children should be exclusively breastfed fed for 6 months and that BF should be continued for two years and beyond (WHO, 2007). Although the knowledge level of exclusive breastfeeding seems to be high in the study population of Male’, half of the population are not aware of the time until which breastfeeding should be continued.

Majority of the study respondents (96%) were aware of the timing of initiation of the CF. A very few percentage of the respondent said that the timing of initiation of CF is at 4 months of age of the child. Despite the higher percentage of awareness of the timing of initiation, only 63% of them had established it at the recommended time. A similar study conducted in Pediatrics OPD Jinnah Hospital, Lahore from March – September, 2012 shows that only 54% of the mothers had the correct knowledge of initiation of CF and 43% of them practiced in the recommended manner (Hasnain, Majrooh & Anjum, 2012). Therefore, the percentage of mothers who started CF at the recommended time is higher in this study.

The study shows that counseling with regard to CF was received by 31% of the respondents. The rest stated that they had never received counseling on CF in any official mean. This could happen due to carelessness in attending the counseling sessions organized by the hospitals and health centers. Most of the participants who have received counseling on CF said that they received it during their antenatal period followed by post delivery period and growth monitoring visits (see figure 8). On the other hand, some of the respondents mentioned that they get information on CF from the internet as well as from family and friends.

In the survey, the prevalence of EBF was 59% which is higher than the results of the Nigeria Demographic Health Survey findings where children who were exclusively breastfed up to 6 months of age was found to be 48% in 2009 (Ministry of Health and Gender, 2014). Even though EBF prevalence is higher than the national findings, there are mothers who had offered only breast milk for their children up to 4-5 months of age and 3-4 months of age and had initiated other sources of food for their child before the age of 6 months. This could be the reason for the higher value.

CF was initiated at the right time by 62% of the respondents. The rest had not attained the appropriate timing of CF, with majority of respondents initiating it earlier than recommended. Earlier initiation was reported by the mothers who felt that the child was not feeding breast milk properly (see figure 10). A similar study done in Mauritius also shows that CF was more commonly initiated around 4-6 months (Motee, Ramasawmy, Gunsam, &Jeewon , 2013).

Another hospital-based cross-sectional study conducted at one private hospital in Salem, Tamil Nadu in 2013, shows that about 62% of the mothers introduced complementary food to their infants before 5 months, while 36 % of introduced at 6 months (Kavitha, Nadhiya, & Parimalavalli, 2014). Various studies show that there are many reasons for early initiation of CF. Some of these includes not having enough breast milk, working mothers having to return to their jobs and feeling that the child needs more than breast milk for better growth (Basnet, Sathian, Malla, &Koirala, 2015).

The study shows that 94% of the respondents follow the recommended meal frequency even though the respondents who follow minimum dietary diversity were comparatively low (51%). A similar study done in Northwest Ethiopia also shows that the proportion of children who met dietary diversity is very much less than that of minimum meal frequency (Beyene, Worku & Wassie, 2015). The possible reasons suggested for in the study could also be the reasons for this in Nigeria. It includes lack of awareness about nutritional requirements for infants and young children, affordability to nutritious food products, tradition of cooking few verities of food for the family and sharing food with all siblings at home.

In the current study, 28% of the respondents who had 1 or 2 children and 13% of the respondents who had more than 2 children are practicing in the recommended way. Thus, it can be concluded that the population who had children less than 3 were practicing most of the recommended CF factors in the best possible manner. So, the number of children can be considered as a decisive factor in the practices of CF. It could be due to the knowledge they had received with the experience from the previous children.

In terms of duration of EBF and CF, the percentage of respondents having less than 3 children and respondents having more than 3 children are 56% and 17% respectively. Hence, it can be concluded that, the recommended timing for duration of EBF and initiation of CF are influenced radically by the number of children in the family. Practices like duration of EBF and initiation of CF are moderately influenced by the number of children in the family. This is congruent to the findings of similar studies. Previous studies revealed that mothers who had at least one child have high levels of breastfeeding related knowledge, including appropriate time of initiating CF. In the study carried out by Shumey, Demissie and Berhane (2013), mothers who had more than one child were 2.344 times higher in initiating CF at six months than mothers who had only one child. This could also be related to repeated exposure of health education during the previous pregnancies and the experience they gained through time, therefore repeated exposure to health education will have an impact in subsequent pregnancies.

The current study revealed that the education level is one of the most important factors affecting the recommended practices as there were 58% of the respondents with higher educated and only 33% of respondents who are less educated respondents practicing EBF and initiation of CF in the appropriate way. A previous study agrees with our finding and reports that higher maternal educational level, high school and above (AOD = 2.361), was noted to increase timely initiation of CF (Shumey, Demissie & Berhane, 2013). This can due to improved maternal education enhancing mothers’ understanding and gratitude of the demands and benefits of introducing CF timely, and empowering them to resist external interferences and pressures.

The percentage of respondents practicing duration of EBF and initiation of CF in the age groups of 32 and below (55%) and above 32 (54%) are almost equal. Therefore, the age of the mother is not a decisive factor for good practices in CF. When the type of family are related with the practices, it is noted that there were 58% of the respondents in nuclear family and 52% of respondents from joint family who had practiced the correct duration of EBF and had initiated CF at the recommended timing. As in these two cases the percentages were differing a bit, it can be stated that the respondents from nuclear family are relatively better than their joint family counter parts. This small difference could be due to the employment status of the mothers.


5.3 Implications

The findings of the study responded to the study’s research questions and helped to achieve its objectives. These findings have several significant implications to determine the baseline information on the level of awareness and practices of CF. Based on the results of this study, further researches can be conducted in a large scale.

Findings of the study could be used by the health planners and health policy makers in Governmental and Non-governmental organization to further improve the practices of mothers regarding infant and young child feeding practices.


5.4 Limitations of the study

As the age of the children ranged up to 12 months, recall period might have introduced recall biases in relation to questionnaires regarding BF and initiation of CF. The study was conducted within a short duration of time. Hence time scale to which the study was undertaken was one of the major limitations. With respect to knowledge and feeding practices all the related factors were not considered in the study due to the time constrain.


5.5 Recommendations

Future research needs to be carried out in order to identify the factors associated with early cessation of BF and earlier initiation of CF. Such information can be used to increase breastfeeding rates, particularly the exclusive breastfeeding rates within the first 6 months after delivery.

The study was undertaken in urban area, similar types of studies are needed to be done in different parts of the countries to understand the level of knowledge and practices of the people on infant and young child feeding. In addition to this, the future studies could include more areas that need to be focused on Infant and young child feeding practices such as hygienic conditions and practices in preparation and storage of food that are provided for the children.


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