Complementary feeding pattern and its impact on growth and development of under 2-years infants in upper Egypt

Exclusive BF till the age of 6 months is rare in developing countries and complimentary feeding (CF) are introduced at an early age which is linked to the development of chronic conditions such as childhood obesity, celiac disease, diabetes, and eczema. The aim of our work is to assess complementary feeding practices of infants under the age of 2 years and to study their impact on their growth and development. This study is a cross-sectional study that was carried out over 3 years between March 2016 and March 2019, included 1000 apparently healthy infants aged less than 2 years old who attended University Children Hospital, Egypt. Practices among mothers including timing and types of foods introduced. Semi-structured questionnaire used for data collection and anthropometric measurements analyzed following the WHO Growth Charts. The study found that about 80% of infants were introduced to solid foods before 4 months of age. Also, a large number of infants were given liquids other than breast milk before completing their fourth month of age. Despite the better mental development of the infants, there is a considerable gap between WHO Guiding Principles for Complementary Feeding and the practices among mothers of infants aged less than 2 years in Egypt.


Background
World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF) recommend exclusive breastfeeding (EBF) for 6 months and addition of complementary foods (CF) at 6 months of age with continued breastfeeding (BF) till 2 years [1,2], while exclusive breastfeeding is recommended for at least the first 4 months of life by European and United State authorities [3,4]. Optimal breastfeeding could prevent up to 13% of deaths of children under the age of 5 years while proper CF practices might have an additional 6% reduction in under-five mortality [5]. Improper feeding practices together with high prevalence of infectious diseases are the main causes of malnutrition during the first 2 years of life [1].
Breastfeeding is common in developing countries, but exclusive breastfeeding is rare and CF is introduced at an early age. Early solid food consumption has been linked to the development of chronic conditions such as childhood obesity, celiac disease, diabetes, and eczema [6]. The second half of the first year of life is a vulnerable time when breast milk alone is no longer sufficient to meet nutritional requirements, so proper complementary feeding should be started [7]. CF bridges the gap in energy, vitamin A, and iron intake, which occurs in breast-fed infants at 6 months of age [8]. The aim of our work is to assess complementary feeding practices of mothers of infants under the age of 2 years and to study their impact on their growth and development.

Methods
A descriptive cross-sectional study was conducted on infants residing one of Upper Egypt governorates and attending well-baby clinic at University Children Hospital. A random sample of 1000 apparently healthy infants who attended for routine check-ups or vaccinations and fulfilling the inclusion criteria, namely, age is less than 2 years, full term and appropriate for gestational age were recruited in the research. Infants with congenital anomalies or suffering from severe illness or chronic disease were excluded from the study. A questionnaire composed of 3 parts was constructed: part 1-socio-demographic characteristics of the index child (age, sex, parents' education, residence, etc.; part 2-detailed feeding history (time of start of BF, CF, duration, etc.); and part 3-clinical assessment of child using standard parameters, developed following the guidelines of WHO. Data collection was done via interviews with mothers. The aim of the study was explained and consent was requested from each mother before interview. Collection of data is from March 2016 to March 2019. Then assessment of infant growth by measuring his/her weight for length percentile, length for age percentile, and head circumference for age percentile and comparing them with standard WHO growth curves [9,10]. Data were collected and analyzed by using SPSS (version 18). Continuous data were expressed in form of mean ± SD or median (range) while nominal data were expressed as frequency and percentage. The odds ratio (OR) and the 95% confidence interval (CI) for each independent variable were derived through regression analysis. P value was significant if < 0.05,

Results
The demographic characteristics of studied infants and their families are shown in Table 1; the mean age (M) of studied infants was 8.12 ± 4.5, about two-thirds of participants (64.3%) were males and the majority (80.2%) lived in rural areas. The mean order of index infant was 2.9 ± 1.7 with an average number of children per family about 3 ± 1.6. The vast majority of mothers (96%) were house wives while the majority of fathers (86.2%) were irregular workers.
Regarding factors affecting patterns of feeding significantly, Table 2 revealed that male sex, rural residence, being the second child in the family and house wife mothers were significantly correlated with higher levels of EBF while mothers who only completed their basic education (completed preparatory education) were associated with higher levels of non-exclusive BF. When mothers were asked about reasons for early introduction of CF before 4 months of age ( Fig. 1), half of the mothers (50%) mentioned that they were advised to introduce CF and about one quarter (24%) reported that lack of knowledge were the main reasons behind CF introduction. When assessing infants' growth and development, Table 3 showed that EBF infants had significantly higher levels of mental development, length for age percentiles. While EBF does not show better motor development or weight for length. Significant predictors for exclusive breast feeding (Table 4) were early starting of breast feeding after birth, male sex of the baby, lower educational level of mother, rural residence, and younger maternal age.

Discussion
Feeding patterns and practices during the first year of life are very important because they will influence growth, development, and morbidity. About three quarters (76%) of the studied mothers have initiated BF within the first hour after birth. This result agrees with Egypt Demographic and Health Survey 2014 (EDHS) and Batal in Lebanon who revealed that 79% and 70% of the children subsequently were initiated BF within the first day after delivery [11,12]. Lower percentages 55.4% and 46.3% were observed in other two studies [13,14]. This might be due to sociodemographic differences including the relatively high level of parental education in our settings. It might also be explained by the low coverage and utilization of maternal health services; particularly poor postnatal care utilization in the Ethiopian study together with missed opportunities during antenatal care visits.
Our study showed that 81.8% of mothers practiced BF which is consistent with results of two studies; 96% in the EDHS study 2014 [12], and 99.6% in a study done in Ethiopia [13]. EBF practice was present in only 24.1% of our studied mothers, in accordance, Saleh in Bangladesh and Roy in India found nearly similar percentages (23% and 28.3% respectively) [15,16] indicating the cultural and traditional nature of the phenomenon. But a much lower percentage was observed by EDHS 2014 which revealed that only 12.5% of studied children were being exclusively breastfed [12] this finding may be due to higher percentage of non-working mothers in our study which allows for EBF. Higher percentages (49.7%) were observed by Caetano in Brazil [17]. On other hand, 63.5% of Indian mothers exclusively breastfed their infants till 6 months of age [18]. These differences of results could be due to differences in socio-demographic factors which affecting feeding practice and level of health education and counseling provided to mothers in various countries.
The most common reasons reported by the mothers for the interruption of EBF in our study were as follows: advice from relative, friend, or even a health care provider (50%), deficient knowledge about proper time of CF starting (24%), perceived insufficient milk production (19%), and child's refusal (3%). Nearly similar results were found by Caetano in Brazil, who stated that the most common causes were insufficient milk production in 17.7% and child's refusal to be breastfed in 8.4% [17]. Batal and Memon explained that by mothers who did not have enough knowledge about EBF benefits, insufficient breast milk, or sickness of some mothers [11,19].  [15]. In our study, only 13.4% of mothers started CF to their babies at age   of 4-6 months, 80.2% before 4 months and 6.4% after 6 months, compared to results of a study in Lebanon revealed that 66% of mothers started CF at age of 4-6 months, 21.9% before 4 months and about 12% after 6 months [11].
In the present study, male infants were 2.4 folds more likely to be exclusively breastfed more than females which is mainly due to gender preference in our community and could be due to physician recommendation as male infants are more susceptible for infectious diseases than females [23]. So, mothers become more careful and do not hasten to introduce CF early to avoid the complications commonly occurring within starting of CF.
The first baby in the family was more likely to be given CF early and about 80% of mothers who introduced CF to their babies early were from rural areas. This may be due to deficient knowledge about timing of complementary feeding starting, low milk production because of poor maternal nutrition and the thoughts and cultural habits of the rural areas. These findings show that illiterate mothers were more likely to early initiate CF compared to highly educated mothers. It agrees with result found in a study in Ethiopia, illiterate mothers were above twofolds more likely to early initiate CF compared to highly educated mothers [13]. On other hand, in Malaysia, educated mothers were 3.5 folds more likely to early initiate CF compared to illiterate mothers [24]. Our results can be explained by the fact that the better educated mothers have good knowledge about the importance of CF practice, might also better understand the message and can use nutrition information resources.
In our study, 94.9% of mothers who gave their infants CF early before the recommended age were not working. Unlikely, in a study applied in Malaysia, working mothers were 3.5 folds more likely to early start CF compared to house wives [24]. A study in Lebanon revealed that employed mothers initiated CF earlier than house wives [11]. It may be explained that most of housewife mothers received lower levels of education and belong to low socioeconomic families, so they started CF early to their babies.
About 56% of mothers started CF with cereals followed by dairy products in 51%, vegetables in 42% then desserts in 38%, and the frequency was the same whatever the time of introduction. Similarly, in a study done in Lebanon, the most common weaning food was cereals in 83.7% [11]. About 80% of studied mothers gave fluids such as water, herbals, and juices to their infants before the 4 months of age, in comparison to Lebanon study, where only 13% of mothers gave liquids before the 4 month of age which reflects the effect of counseling and health education [11].
In our study, about 45.0% of exclusively breastfed infants were physically delayed, while about 33% of nonexclusively breastfed infants were physically delayed. This could be explained by the low vitamin D content in the breast milk unlike milk formula and other specific food types [25,26]. We found that 25.7% of EBF infants were wasted and 33.6% were stunted, while 30.0% of non-EBF infants were wasted and 17.0% were stunted. This large portion of physically delayed, wasted, and stunted infants may be due to the low socioeconomic level, poor maternal nutrition, and early and faulty introduction of complementary foods.
Regression analysis of our study revealed some of the significant determinants of EBF; early breastfed infants after delivery, male infants, infants that came from urban areas, infants of older mothers group, infants whose mothers were not educated, and infants whose fathers were not working were more likely to be exclusively breastfed than infants of other corresponding groups, respectively.

Conclusion
Complementary feeding practices among studied mothers of infants under the age of 2 years in Upper Egypt were extremely far from the WHO guidelines. About three-quarter of studied mothers introduced CF to their infants early before the recommended age. Mental development was better in exclusively breastfed infants than those given CF early. Insufficient knowledge about proper timing of CF was the main reported factor by mothers for early introduction of food. Early breast feeding, paternal occupational status, male sex, and low maternal education predicted proper timing for CF.