Complementary Feeding:Preventing the Plunge
Marcia GriffithsThe Manoff Group
-1.6
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-1
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Malnutrition is a process
Nutritional Status Weight-for-Age
-1.6-1.4-1.2
-1-0.8-0.6-0.4-0.2
0
3 6 9 12 15 18 21 24
Age (months)
Z s
core
The Pattern is Universal
Shrimpton, R. et al. Pediatrics 2001;107:e75
Pattern of Chronic Malnutrition
Shrimpton, R. et al. Pediatrics 2001;107:e75
Result of Early Insults
The Prevention Paradigm—an unfinished agenda
Lancet endorsement of complementary feeding promotion—education and supplementation
19.8% relative reduction in stunting 0-12mo.
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-1.4
-1.2
-1
-0.8
-0.6
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0
3 6 9 12 15 18 21 24
BF Complementary Feeding
Hygiene and Healthcare
The Complementary Feeding Balancing Act
Is age-dependent:
The 6 – 24 month group is not monolithic
6-8/9
9-12
13-18
19-24
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-1.4
-1.2
-1
-0.8
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3 6 9 12 15 18 21 24
BF Complementary Feeding
The Complementary Feeding Balancing Act
Multiple behaviors
and multiple paths to reach goal of improved nutrient intake
• Breastfeeding-----Complementary foods• Nutrient density-----Food consistency/dilution• Frequency of feeding----Nutrient density• Frequency of feeding----Quantity per feeding
-1.6
-1.4
-1.2
-1
-0.8
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0
3 6 9 12 15 18 21 24
BF Complementary Feeding
The Complementary Feeding Balancing ActRequires cultural and individual specificity
Example of feeding frequency: Different cultural practicesKazakhstan—feeding approx 10 x/day Marie Biscuits and teaC. America—feeding about 2-3 times, not in the afternoonGujarat—feeding once with 2 snacks, child should feel hunger
Individual tailoring:Mother works at home Mother is still fully breastfeeding
-1.6
-1.4
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-1
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0
3 6 9 12 15 18 21 24
BF Complementary Feeding
How Are We Doing?
0%
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30%
40%
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70%
<50% 50-75% >75%
Percent of Countries
Percent of Infants Meeting Indicator
Continue to Breastfeed (From 43 Countries)
Murkuria, A, et. al. 2006. Infant and Young Child Feeding Update. ORC Macro: Calverton, MD.
How Are We Doing? Adequate Dietary Diversity (from 37 countries)
0%
10%
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< 50% 50-75% > 75%
Percent of Countries
Percent of Infants Meeting Indicator
Murkuria, A, et. al. 2006. Infant and Young Child Feeding Update. ORC Macro: Calverton, MD.
How Are We Doing?
Adequate Feeding Frequency (From 35 countries):
0%
10%
20%
30%
40%
50%
60%
< 50% 50-75% >75%
Percent of Countries
Percent of Infants Meeting Indicator
Murkuria, A, et. al. 2006. Infant and Young Child Feeding Update. ORC Macro: Calverton, MD.
How Are We Doing?
Composite of 3 practices
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<50% 50-75% >75%
Percent of Countries
Percent of Infants Meeting Indicator
Murkuria, A, et. al. 2006. Infant and Young Child Feeding Update. ORC Macro: Calverton, MD.
How Can We Change This Picture?
Resources• Global Strategy on Infant and Young Child Feeding,
2002• Guidelines for the Complementary Feeding of the
Breastfed Child, WHO/PAHO, 2001• Guidelines for the Complementary Feeding of the
Non-Breastfed Child, WHO, 2005 • Indicators to track progress—WHO and DHS
• Tools to gather caregiver input on behavioral recommendations
Designing by Dialogue
ProPan• Old and new program strategies• Old and new technologies and products• Partnerships • Creativity
How Can We Change This Picture?
How to Strengthen Performance
1. Listen and learn from caregivers
2. Plan strategically
3. Improve access to quality food choices
4. Focus on practices including those not measured
5. Provide tools to help implementation of key practices
6. Provide tailored advice and demonstrations
How to Strengthen Performance
1. Listen and Learn from caregivers• Big picture: DHS or other survey data• Explore REASONS behind reported practices
(determinants of current behavior)• Also explore reactions to new/modified behaviors
(determinants of new behavior)
Trials of Improved Practice
Three step home visit protocol:
1. Exploratory visit
- Analysis: rank feeding problems develop recommendations
2. Counseling/ negotiation visit
- TRIAL
3. Follow-up visit
Examples of Insights
• Green leafy vegetables: - difficult to digest (Indonesia)
+ bayam, finely chopped and well-cooked
• Animal Foods: - unaffordable (Swaziland)
+ father purchase/ duty to child
• High frequency of snacks: - child is too fussy/calms child (Kazakhstan)
+ a meal reduces fussiness
• Assisted feeding: - too busy, hard, child needs to learn
+ feed child/ animals; to learn; need to teach; if child eats takes less time later
Results
• Prioritize key elements among the many factors• See similarities and differences across a country
- Scale- up addressing common themes
- Develop regional or village variations where needed
How to Strengthen Performance2. Complementary feeding is behavioral, requiring a strategic
approach
Legislation•Code of marketing breastmilk substitute •Code of marketing infant foods- safety
Communication
•Advocacy for attention to child feeding•Promote critical child feeding concepts•Promote specific, over-arching, improved practices •Counseling•Demonstrating
Training
•Healthcare professionals•Develop a community cadre•Agriculture extension
Partnerships
•Private sector•Local vendors, shop owners•Women’s organizations
Products
•Local recipes•Home fortificant•Commercial food•Bowl, spoon•Tippy Tap
How to Strengthen Performance
3. Improve access to as many quality food choices as possible:
home made combinations,
improved vendor foods,
home fortificants—powders and spreads,
commercially processed foods
Homemade Mixed Foods—Achievements
Indonesia: Homemade, Bubur campur
Zeitlin et al. 1984 Household Evaluation: Nutrition Communication and Behavior Change Component. Manoff International: Washington, D.C.
Homemade Mixed Foods—Achievements
Zeitlin et al. 1984 Household Evaluation: Nutrition Communication and Behavior Change Component. Manoff International: Washington, D.C.
Indonesia: Homemade, Bubur campur
How to Strengthen Performance
4. Don’t forget about practices that are not part of an indicator
Ex. Hygiene,
Use of oil/fat
Responsive or assisted feeding, and
Food quantity per serving
Quantity is a problem that becomes acute in the second year of life.
Food QuantityFrom Honduras—2002
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Breastfeeding Frequency of Feedingper Recommendation
Breastfeeding andFrequency Combined
Appropriately Fed BF,Frequency and
Amount
Perc
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t
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Breastfeeding Frequency of Feedingper Recommendation
Breastfeeding andFrequency Combined
Appropriately Fed BF,Frequency and Amount
Feeding According to Recommendations: Children 12-23 Months
Feeding According to Recommendations: Children 9-11 Months
Food Quantity--Issues• Caregivers have no idea how much a child should
receive• Caregivers do not think it is possible for a small child
to eat “so much”• Caregivers often report being afraid that their child
will get sick from eating “too much”• Sometimes caregivers say that they do not want their
child to get accustom to feeling full, to always being satisfied
• Counseling materials with pictures of the number of spoons of food needed at each meal not clear or memorable
How to Strengthen Performance
5. Provide tools to help the implementation of critical practices
Ex. Child Feeding
Bowls
Countries:
Nicaragua
El Salvador
Bolivia
Child Feeding Bowls
• Bowl models have been different in each location• All have markings to denote appropriate quantity of
food for each age• The bowls allow a mother/older sibling to offer the
appropriate amount of food and to see how much the child eats.
Child Feeding Bowl--Trial
• In June/July 2008, in Santa Cruz area of Bolivia, use of bowl assessed
• Qualitative study using TIPs method• Bowl introduced to 28 of 82 participating mothers
whose children (6 – 22 mo) had especially poor reported food intake
Child Feeding Bowl--Result
• All mothers with bowls used them, and were successful in increasing food quantity to the amount indicated by the bowl for the child’s age.
“the bowl gives good results and my child eats more when he eats from his own plate. I can measure how much he eats and he likes the bowl”.
• Use of the bowl seemed to motivate improvement in other practices: feeding more frequently and separating the child’s food from the family’s.
Child Feeding Bowl--Result• Fathers took interest in the bowl and therefore in feeding their
child
• Older children took ownership of their bowls and asked for food
Child Feeding Bowl--Conclusion
• High acceptability—everyone wanted one• Made instruction/counseling easier• Served as an effective reminder about feeding• Inexpensive ($0.22 – $0.38)• Easily scaleable
How to Strengthen Performance
6. Provide Tailored Advise and Demonstrations
• Mothers often don’t know what to do – advice is not easily available
• New concepts- ex. expansion of grains and food consistency
• New skills- mashing food, using greens, beans• Influence of internal barriers – sense of self
confidence and self- efficacy
Counseling Aids & Demonstrations
Counseling Aids & Demonstrations
Counseling Skills
Counseling at Health Services-- Specific Advice on PracticesChildren meeting local energy requirement
Counseled Not Counseled
At 8 months 82% 73%
At 12 months 62% 51%
Stunting at 18 months: 5% 16%
• At 18 months children of “counseled” mothers- 1 cm taller
Penny, ME. et al. 2005. Effectiveness of an Educational Intervention Delivered Through the Health Services to Improve Nutrition in Young Children: A Cluster Randomized Controlled Trial. The Lancet, 365:1863-1872.
Improving Complementary Feeding
• It is our “opportunity” / our failure• Call for strategies: policies, programs and tools built
to answer local need • Programs will not look the same but they should
consider similar themes
• High coverage• Are key practices improving?• Are nutrient intakes improving?• Is the growth failure gap narrowing?
Improving Complementary Feeding– The Bottom Line
Will these two children experience the same outcome?