Rates of malnutrition among children usually peak between 6–24 months, the time of complementary feeding. During this period other foods or liquids should be provided along with breastmilk. The second half of the first year is an especially vulnerable time because infants are learning to eat and must be fed soft foods frequently and patiently.
A single indicator cannot give a complete picture of this complex feeding behavior.The timely complementary feeding rate—an accepted, standard indicator—reflects general dietary intake of solid and semi-solid foods along with breastmilk during a specified time period. The indicator does not, however, capture factors such as quantity and quality of food, frequency and timeliness of feeding, food hygiene, and feeding during/after illness.
AED programs have helped improve these complex aspects of feeding, as well as provide meaningful measures of these practices.
Timely complementary feeding among infants 6 through 9 months old
The complementary feeding indicator
[1] is sensitive only to late introduction of complementary foods in addition to breastmilk, while in fact it is more common that foods are introduced too early rather than too late. In LINKAGES countries where this indicator was measured, only Ethiopia had a very high rate of late introduction of foods at baseline and showed significant improvement after the program intervention, from 40 percent to 60 percent. In program areas in other countries, the baseline rate was high and remained high.
Infant and young child feeding among children 6 through 23 months old
New complementary feeding indicators that will provide richer and more programmatically relevant information are being developed and tested. AED is working with the World Health Organization and other groups to define such indicators.
Several iterations of complementary feeding indices (e.g., the young child feeding index [2]) and indicators have been developed. The infant and young child feeding (IYCF) indicator is being adopted by USAID and will likely be integrated into future Demographic and Health Surveys. Three key feeding behaviors among children 6–23 months old make up all of the new complementary feeding indicators being discussed or proposed: 1) continued breastfeeding, 2) age-appropriate frequency of feeding, and 3) dietary diversity (food group diversity)
The criteria for the new IYCF indicator adopted by USAID are shown in the following table.
Table: Criteria for IYCF Indicator
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Criteria for Breastfed Children 6–23 months
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Criteria for Non–Breastfed Children 6–23 months
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Continued breastfeeding
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Fed breastmilk substitute
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Frequency of feeding of complementary foods
6–8 months old: 2+ times
9–23 months: 3+ times
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Frequency of feeding of complementary foods
6–23 months: 4+ times
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Dietary diversity
3+ food groups
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Dietary diversity
4+ food groups (with dairy products as one of the groups)
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LINKAGES’ surveys in 2005 and 2006 included questions that permitted calculation of the IYCF indicator. The Madagascar endline survey in 2005 showed very favorable results compared to national results from the 2003 DHS. In Ethiopia, however, program area results in Oromia in 2006 were not significantly different than the DHS results in 2003–2004. (See figure 2.)
Selected Past Programs—Burkina Faso and Mali
More than a decade ago, AED carried out several successful programs to influence some of the challenging aspects of infant feeding. Formative research focused on the quantity, quality, and frequency of giving complementary foods, as well as the timing of introducing these foods. Local care practices associated with feeding were also studied Trials of Improved Practices, or TIPs, played a crucial role in determining what kinds of changes would have the most impact and would be feasible and acceptable to families.
Several programs also looked at the role of the father in supporting family nutrition, including providing the mother with extra cash to purchase qualify foods, or bringing home specific snacks from the market.
Mali
USAID's Nutrition Communication Project (NCP), managed by AED, worked in Mali from 1989-1995 and collaborated with a number of non-governmental organizations to introduce a nutrition emphasis into their ongoing programs. NCP worked closely with the Nutrition Service of the Ministry of Health and gradually transferred technical leadership to the newly formed National Center of Information, Education, and Communication for Health (CNIECS). This "Nutrition Network" gradually grew to include three government ministries, ten local and international NGOs, and several donors including UNICEF, USAID, and the Food and Agricultural Organization. Project activities were carried out in four regions of Mali.
The National Literacy Service of the Ministry of Education was also an active partner and worked to improve the nutrition curriculum in primary schools and incorporate nutrition messages into adult literacy materials.
The project aimed to improve rates of exclusive breastfeeding for up to 6 months, followed by consumption of nutrient-rich complementary foods. Other objectives focused on child feeding during and after illness and improvements in the diets of pregnant and lactating women.
The communication strategy relied heavily on counseling and group talks by health workers, supported by training and materials to help health workers negotiate changes in individual practices. Radio extended the reach of the program and motivated communication agents. A popular theater group helped develop scripts for community activities and role plays, which made good use of humor to highlight the issues of inter-family food allocation and men's roles in family nutrition. The radio drama series featured a recalcitrant father, who, with the advice of the community health agent and the meddling of various village characters, finally gets his family on the "Road to Health."
Target behaviors focused on mothers as well as fathers. Improved practices related to nutrition during pregnancy and lactation, breastfeeding and appropriate feeding of children at 6 months of age, discrete child feeding behaviors (at least three supervised meals a day, use of a separate feeding bowl for children 12-36 months old, and recuperative feeding skills); proper food choices to prevent and cure vitamin A deficiency, and healthy food choices in the market. Men were encouraged to purchase snacks for their wives and children, and also to provide cash to their wives in order to meet their nutritional requirements and those of their young children.
The evaluation included a 24-hour dietary recall and weighing and measuring of children three years of age and younger. Mothers in program villages were more likely to introduce porridge, fruit, green leafy vegetates, cow's milk, and meat or liver into a child's diet in a reasonable time than mothers in comparison villages.
The prevalence of acute malnutrition among children under 3 years of age (weight-for age less then 2 standard deviations below the WHO/NCHS reference standard) was reduced from 38 percent to 28 percent in program villages, while it remained virtually unchanged (1 percent increase) in comparison villages.
Chronic malnutrition, or stunting (height-for-age) was reduced from 46 percent to 31 percent in the program villages, with no significant change in comparison villages.
There was a positive relationship between the length of time a village participated in the project and the improvements in children's measurements. Exposure was also strongly correlated with increases in several promoted behaviors:
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Men purchased healthier foods for women and children;
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Women and children consumed larger amounts of healthy foods; and
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Caretakers reported better child feeding practices, such as the use of a separate bowl and more purposeful feeding.
The program also included a cost analysis study. Two outcome measures were used: number of children saved from malnutrition and 2) number of child lives saved as a result.
In terms of external project funds, the program cost $101 per child saved from underweight and $76 per child saved from stunting. In looking at death from malnutrition (either as a direct cause or a contributor to death by infectious diseases and other causes), an estimated 3,822 children's lives were saved as a result of the project, at a cost of $282 per child.
Burkina Faso
USAID's Nutrition Communication Project, managed by AED, also worked in Burkina Faso from 1989-1995 in eight provinces with a total population of 2.5 million people. The project aimed to improve rates of exclusive breastfeeding for up to 6 months, followed by consumption of nutrient-rich complementary foods. Other objectives focused on child feeding during and after illness and improvements in the diets of pregnant and lactating women.
As in Mali, the communication strategy relied heavily on counseling and group talks by health workers, supported by training that focus on building specific skills. Various strategies helped "jump-start" activities, including adapting approaches and print materials developed in neighboring Mali as well as Niger, and MOH staff exchanges among the countries. The Burkina program included community theater and radio dramas. Agricultural extension agents were also trained to promote improved food production techniques to villagers. Messages were integrated into the national Literacy program, and a related child-to-child program was launched in the schools, with assistance from UNICEF and Helen Keller International.
Messages focused on mothers as well as fathers, who were encouraged to provide extra food or money for food to wives who were pregnant or breastfeeding, to help wives to find others to do the heavy labor during the last trimester of pregnancy, and to purchase snacks for both wives and children.
An evaluation found that more than half the population were exposed to at least one source of program information. If a man's wife was exposed to project media, or if he was exposed to the media, he brought home twice as many of the promoted healthy foods as men who were not exposed. The more media the respondents were exposed to (five channels were tested) the higher their scores on survey questions of knowledge and reported behavior.
The figure below shows changes in knowledge and practices about how a child should be fed (actively encouraged to eat), the correct timing for introducing solid foods, continued breastfeeding, and the role of the father in supporting a child's diet.
[1] The timely complementary feeding rate is the percentage of infants 6 through 9 months of age who receive breast milk and a solid/semi-solid food (based on 24-hour recall). Solid foods are defined as foods of mushy or solid consistency, not fluids.
[2] Arimond M. and Ruel M. Generating Indicators of Appropriate Feeding of Children 6 through 23 Months from the KPC 2000+, FANTA Project, Washington, DC: AED, November 2003.
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