Feeding Practices of Children Under 2 years of age attending Immunization Clinic at a Tertiary Care Hospital in New Delhi

Presented by:

Introduction
The period during pregnancy and a childs first two years of life are considered a critical window of opportunity for prevention of growth faltering. After birth, a childs ability to achieve the standards in growth is determined by the adequacy of dietary intake (which depends on infant and young child feeding and care practices and food security), as well as exposure to disease. Undernutrition and infection are intertwined in a synergistic vicious cycle. Therefore, support to quality child feeding practices together with disease prevention and control are the most effective interventions that can significantly reduce stunting and acute malnutrition during the first two years of life. Of all proven preventive health and nutrition interventions, IYCF has the single greatest potential impact on child survival. Therefore, reduction of child mortality can be reached only when nutrition in early childhood and IYCF specifically are highly prioritized in national policies and strategies.

Growing evidence points to the impact of early initiation of breastfeeding on neonatal mortality. Breastfeeding, especially six months of exclusive breastfeeding, continued breastfeeding from 6 to 23 months has a significant effect in the reduction of mortality from the two biggest contributors to infant deaths: diarrhoea and pneumonia, as well as on all-cause mortality [4]. This study is intended to find out the feeding practices of children under 2 years amongst those who are coming in contact with the health system and in whom the aspect of prevention of infectious diseases is being addressed to determine the extent of deficiencies still existing in the aspect of appropriate infant and young child feeding practices.

Aims & Objectives

To calculate the percentage of women practising exclusive breastfeeding amongst those attending the immunization clinic at a tertiary care hospital. To study infant and young child feeding practices amongst the study subjects

Review of Literature
Amir Maroof Khan et al, in 2012, conducted a study on infant and young child feeding practices among mothers attending an urban health center in East Delhi. Their results showed that 38% of the children were given prelacteal feeds and 37.2% were put on breastfeeding within 1 hour of birth. 57% of the children under 6 months were given exclusive breastfeeding.62% of the children between 6 and 9 months were having complementary feeding. Minimum Dietary Diversity was observed only in 36.2% children. Minimum Meal Frequency was observed in 48.6% children. Minimum Acceptable Diet was found to be adequate in only 19.7%. Bottle feeding was observed in 26.5%.

Review of Literature
Kunwar, et al, in 2010, studied the pattern and determinants of breast feeding and contraceptive practices among mothers within six months postpartum. Of all women interviewed only 75.8% practiced exclusive breast feeding with the mean duration of exclusive breast feeding (EBF) being 3.5 months with only 41% practicing EBF for six months. Better education was the only factor significantly affecting EBF (p< 0.004) . Kishore et al, in 2008 studied Breastfeeding Knowledge and Practices amongst Mothers in a Rural Population of North India. Out of the 77 mothers, 30% and 10% exclusively breastfed their infants till 4 and 6 months of age, respectively. Thirty-nine percent of the mothers had satisfactory breastfeeding knowledge. Lack of breastfeeding counselling was significantly associated with decreased rates of EBF at 4 months and 6 months

Review of Literature
According to NFHS III, 46.3% of infants (0-6 months) are exclusively breastfed. Only 44 percent of breastfed children are fed at least the minimum number of times recommended, but only half of them also consume food from three or more food groups. Feeding recommendations are even less likely to be followed for non breastfeeding children age 6-23 months. More than four out of five children in this group were given milk or milk products the day before the survey, but only 31 percent consumed food from four or more food groups, as recommended. Even fewer children (27 percent) are fed four or more times a day. Only 12 percent of non breastfed children are fed with all three infant and young child feeding (IYCF) practices. When breastfeeding and non breastfeeding children are combined, it is clear that most children age 6-23 months are not fed according to the IYCF recommendations. Only 21 percent are fed appropriately according to all three recommended IYCF practices. The percentage of children given food from the appropriate number of food groups and the percentage fed with all three IYCF practices increase steadily with age and the wealth index and generally increase with the mothers education

Review of Literature
Rasania et al, in 2003, studied breastfeeding practices in a Maternal and Child Health Centre in Delhi. Exclusive breast-feeding up to four months of age was practiced only by 26.6 % of the mothers. A more significant (P<0.001) correlation with the initiation of breast-feeding practice to the literacy status of mothers was observed. Frequency of breastfeeding was also reported less amongst the illiterate women. Mainly, it was illiterate mothers who reported problems during breast-feeding. Approximately two-third of the mothers preferred to provide their children something other than breast milk. Graduate mothers wanted to supplement more compared to other literate ones. Irrespective of the literacy status, 65.8 percent of mothers were found using bottles for top feeding their children.

Material & Methods

Study Design: Cross sectional study Study Area: Immunization Clinic, Safdarjung Hospital, New Delhi Study Period: from 5th to 16th of July, 2013 Study Population: children under 2 Years of age attending the Immunization Clinic accompanied by their Mothers/Primary care givers Sampling Technique: Non-probability sampling Using data from NFHS-3, prevalence of exclusive breastfeeding under 6 months of age is 46.4%.

Applying formula, sample size > 4pq/l2 Where, p=prevalence, q= 1-p and l=precision (10%) With this a sample size of 110 was obtained. Another 10% of was added to obtain Final Sample size of 120.

Materials & Method (Contd.)

Study Instrument: Pre-tested, Semi-structured, Interview based questionnaire including questions from the standardized IYCF(Infant and Young Child Feeding) questionnaire. An informed consent was taken. Inclusion criteria: All women with children under 2 years of age Exclusion criteria: Women whose children were severely ill. Women who refused to consent. Statistical analysis: Using the software SPSS ver.16.0. The data evaluated using chi square test . P value less than 0.05 was considered as statistically significant.

RESULTS

Socio-demographic Profile
Table2.Age and Sex-wise Distribution of the study subjects
Age(in months)/Sex Male <6 17(24.6%) Female 22(43.1%) Total 39(32.5%) n=120

6-12
12-18 18-24 Total

19(27.5%)
11(15.9%) 22(31.9%) 69

11(21.6%)
7(13.7%) 11(21.6%) 51

30(25%)
18(15%) 33(27.5%) 120

Table3.Distribution of the study subjects according to Kuppuswamys Socioeconomic scale(revised for 2012)
n=120

Socioeconomic status Upper lower Lower middle Upper middle Upper Total

Frequency 19 40 51 10 120

Percentage 15.8% 33.3% 42.5% 8.3% 100

Table4.Distribution of the study population on the basis of mode and place of delivery
Frequency MODE OF DELIVERY Normal vaginal Caesarean Instrumental PLACE OF DELIVERY Institutional Non-Institutional 101 16 3 108 12
n=120 Percentage

84.2% 13.3% 2.5% 90% 10%

INDICATORS
CORE IYCF INDICATORS Exclusive Breastfeeding Initiation of Breastfeeding OPTIONAL IYCF INDICATORS (computed from the study) Children ever breastfed Age appropriate breastfeeding

Initiation of Complementary Feeding

Still Breastfeeding

Bottle feeding
Milk feeding frequency of non breastfed children

Minimum dietary diversity Minimum meal frequency Minimum acceptable diet

Fig.1Children currently breastfed and children ever breastfed amongst the study subjects
140 120 100
103(85.8%)

n=120 120(100%)

80 60 40
20 0 Children currently breastfed 17 0 Children ever breastfed

Yes
No

85.8% of children under two years were currently breastfed 100% of the children under 2 years had been breastfed in the past

Table5.Distribution of children currently breastfed according to age

n=120 Age(in No. Of children in months) each age group <6 6-12 12-18 18-24 Total 39 30 18 33 120 Currently Breastfed

39 26 18 20 103

100% 86.7% 100% 60.6% 85.8%

100% of children under 6 months were currently breastfed

Fig2.Children under 6 months who were exclusively breastfed in the last 24 hours

Odedump=0.54 Odkkuppup=0.63

79.5%

(n =39)

20.5%

Yes(31)

No(8)

79.5% of children under 6 months were exclusively breastfed in the last 24 hours

Fig3. Adequacy* of Breastfeeding amongst those exclusively breastfed in the last 24 hours
n=31

14

17

On demand Atleast 6 times a day

54.8% of the mothers of those under 6 months of age who were exclusively
breastfed in the last 24 hours breastfed their child on demand

*IMNCI guidelines state that breastfeeding on demand or atleast 6 times in 24 hours is adequate

Fig4.Frequency distribution of Initiation of breastfeeding in time

50 40 30 34(28.3%) 21(17.5%) 47(39.2%)

Kuppup=0.63 Podp=0.46

n=120

20
10 0

17(14.2%)

Immediately

Within 1hour

between 1- >24 hours 24 hours

42.5% of women initiated breastfeeding within 1 hours

Fig.5Percent receiving Pre-lacteal feeds

n=120

49(40.8%) 71(59.2%) Yes No

40.8% of the children under the study had been given pre-lacteal feeds

Fig6.Distribution of study subjects given pre-lacteal feed according to educational status of primary care giver
n=120 P value=0.026

Total in each Education Level group

Number given pre-lacteal feeds Percentage 22 28 26 22 22 13 59% 17 60.7% 8 30.7% 5 22.7% 6 27.3%

Less than primary level

Primary Secondary Senior Secondary Above

Fig7.Distribution of those receiving pre-lacteal feeds on the basis of gender n=120 P value=0.003

GENDER OF CHILD Males

YES

NO

TOTAL

36 (52.12%)

33 (47.88%)

69

Females

13 (25.5%)

38 (74.5%)

51

Fig8.Percent receiving specific Pre-lacteal liquids

1(2%) 2(4.1%)

Pre-lacteal liquids given

n=120 Milk other than breastmilk Honey Plain water

7(14.3%)

23(46.9%)
5(10.2%)

Janamgutti Sugar water Tea

11(22.4%)

The most commonly(46.9%) given pre-lacteal liquid was found to be milk other than breast milk

Fig9.Continued Breastfeeding beyond 6 months of age AGE IN MONTHS TOTAL CONTINUED BREAST FEEDING 15 (100%) 3 (37.5%)

12-15 20-23

15 8

Continued breastfeeding is 100% at 1 year while it is only 37.5% at 2years of age

Fig10.Prevalence of bottle feeding amongst total study subjects

n=120

36, 30%
NOT BOTTLE FED BOTTLE FED

84, 70%

Fig11.Prevalence of bottle feeding in mothers who were working amongst the study subjects

Total

Bottle feeding

Not bottle feeding 4 (30.6%)

Working Mothers Homemakers

11

7 (69.4%)

109

29 (26.6%)

80 (73.3%)

Fig12.Distribution of bottle fed children under 2years according to educational status of mother
n=120 P value=0.026 Total in each Education Level group Number of bottle fed Percentage 22 28 26 22 22 3 13.6% 9 32.1% 3 11.5% 11 50% 10 45.5%

Less than primary level

Primary Secondary Senior Secondary Above

Fig13.Percent subjects in the age group 6-8 months to whom solid, semi-solid or soft foods were given in the last 24 hours
16 14 12 10 8 6 4 2 7(50%) 14 Total children between 6-8 months of age Those receiving complemenatry feeds n=14

Fig14.Children between 6-24 months receiving a minimum of 4 food groups(Minimum Dietary Diversity) in the last 24 hours
18(22.2%)

Edum p=0.446

n=81 those receiving minimum dietary diversity

those receiving less than 4 food groups

63(77.8%)3

Total children between 6-24 months receiving minimum dietary diversity =22.2%

Fig.15Distribution of those receiving minimum dietary diversity according to socioeconomic status

n=81 P value=0.03 Socio-economic Status TOTAL MINIMUM DIETARY DIVERSITY 0 4 10 4

Upper Lower Lower Middle Upper Middle Upper

12 26 34 8

Fig16.Children between 6-23 months receiving minimum meal frequency in the last 24 hours

AGE

TOTAL

MINIMUM MEAL FREQUENCY RECEIVED 5(35.7%) 29(58%) 17(100%)

Breastedfed

6-8 months 9-23 months

14 50 17

Non BreastFed

6-23 months

Fig17.Children between 6-23 months receiving minimum acceptable diet in the last 24 hours

AGE

TOTAL

MINIMUM ACCEPTABLE DIET RECEIVED 0 12(24%) 3(17.6%)

Breastedfed

6-8 months 9-23 months

14 50 17

Non BreastFed

6-23 months

Fig18.Distribution of those receiving minimum acceptable diet in the last 24 hours according to socioeconomic status Socio-economic Status TOTAL MINIMUM ACCEPTABLE DIET RECEIVED 0 4(15.4%) 7(20.6%)

Upper Lower Lower Middle Upper Middle

12 26 34

Upper

4(50%)

n=81 P value=0.04

Fig19.Prevalence of age appropriate breastfeeding amongst breastfed study subjects AGE TOTAL CHILDREN AGE APPROPRIATE BREASTFEEDING RECEIVED 31(79.5%)

<6 months

39

6-23 months

81

54(66.7%)

Total children under 24 months receiving age appropriate breastfeeding=(31+54=85/120=)70.8%

Edump=0.385 Kuppup=0.874

Fig20.Percent non breastfed receiving adequate milk feeds in the last 24 hours
20 17 15 10 5 15(88.2%) n=17 Edump=0.365 Kuppup=0.922

Total children

Children receiving adequate milk feed frequency

0
Non breastfed children above 6 months

88.2% non breastfed children receive adequate milk frequency

Core IYCF Indicators

120.00% 100.00% 80.00% 79.5% 100.0%

60.00%
42.5%

50.0%

40.00%
20.00% 0.00% Early Initiation of Exclusive Continued breast Breastfeeding breastfeeding for 6 feeding at 1 year months of age of age Introduction of solid, semi-solid and soft foods

Core IYCF Indicators

50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 22.2% 17.3%

43.3%

5.00%
0.00% Minimum dietary diversity Minimum meal frequency Minimum acceptable diet

Additional IYCF Indicators

120% 100% 80% 60% 40% 20% 0% children ever Continued Age Bottle feeding Milk Feeding breastfed breastfeeding appropriate Frequency in at 2years breastfeeding Non Breastfed children 37.5% 30.0% 100.0% 70.8% 100.0%

In addition to the above core IYCF indicators, the study also revealed the status of the following additional indicators:
Table1.A summary of additional IYCF indicators computed from the study
S.No. 1. IYCF Indicators Children ever breastfed Value 100%

2. 3.
4. 5. 6.

Age appropriate breastfeeding Bottle feeding

Minimum dietary diversity Minimum meal frequency Milk feeding frequency of non breastfed children

70.8% 30%
22.2% 62.9% 88.2%

RESULTS
In the study, out of 39 children under 6 months of age, 31(79.5%) had been exclusively breastfed in the last 24 hours. Amongst the 120 study subjects, breastfeeding was initiated within 1 hour of birth in 42.5%(51/120) subjects Percentages of children still breastfeeding in the age groups 12-15 months and 20-23 months were 100% (15/15)and 37.5% (3/8)respectively. Complementary feeds had been introduced in only 50%(7/14) of those in the age group of 6-8 months Amongst children above 6 months of age only 18.5%(15/81) received the minimum acceptable diet. 50% of children between age group 6-8 months were receiving complementary feeds.

Discussion
In the study, 100% of mothers had been found to have breastfed their child. This is higher than that reported by NFHS-3 for Delhi(95.6%). Amongst those under 6 months 79.5% were exclusively breastfed in the last 24 hours which is also considerably higher than that reported by NFHS-3 (46.4%). 42.5% initiated breastfeeding within 1 hour of birth which is consistent with NFHS-3 data for Delhi(42%) Only 50% of those in the age group of 6-8 months received complementary feeds which is near that reported by DHS 2002-08 (54.5%) Amongst children above 6 months of age only 18.5% received minimum acceptable diet which is higher than that reported by DHS 2002-2008(7.1%).

 Continued breastfeeding at 1year of age was 100% which ih higher than that reported by DHS 2002-2008 (75%) for developing countries while at 2 years of age was only 37.5% which is considerably lower than that reported by DHS 2002-2008 (56%) for developing countries .

 The percentage of children having received pre-lacteal feed was 40.8% which are rather optimistic figures compared to those of NFHS3 for Delhi(45.5%) amongst whom it was twice as common amongst males(52.5%) and amongst mothers with a poor educational status(P value < 0.05).The latter is consistent with NFHS-3 data.

 Bottle feeding was seen in 30% of the study subjects which is higher than those reported by NFHS-3 (14.01%) and was more common amongst working mothers and those with a higher educational status. This substantiates the fact that educated working mothers spent more time outside their home and were compelled to adopt alternative feeding practices for their children