Feeding practices and growth of infants from birth to 12 months in the central region of the Limpopo Province of South Africa

Maternal education and its influence on child growth and nutritional status during the first two years of life: a systematic review and meta-analysis

Background

The first 1000 days of life are critical for a child's health and development. Impaired growth during this period is linked to increased child morbidity, mortality, and long-term consequences. Undernutrition is the main cause, and addressing it within the first 1000 days of life is vital. Maternal education is consistently identified as a significant predictor of child undernutrition, but its specific impact remains to be determined. This study presents a systematic review and meta-analysis investigating the influence of high versus low maternal education levels on child growth from birth to age two, using population-based cohort studies.

Methods

Databases including PubMed, Scopus, EMBASE, Web of Science, ERIC, and Google Scholar were searched from January 1990 to January 2024 using appropriate search terms. We included population-based cohort studies of healthy children aged two years and under and their mothers, categorizing maternal education levels. Child growth and nutritional outcomes were assessed using various indicators. Two reviewers independently conducted data extraction and assessed study quality. The Newcastle Ottawa scale was utilized for quality assessment. Random-effects models were used for meta-analysis, and heterogeneity was assessed using the Cochrane Q and I2 statistic. Subgroup and sensitivity analyses were performed, and publication bias was evaluated.

Findings

The literature search retrieved 14,295 titles, and after full-text screening of 639 reports, 35 studies were included, covering eight outcomes: weight for age z-score (WAZ), height for age z-score (HAZ), BMI for age z-scores (BMIZ), overweight, underweight, stunting, wasting, and rapid weight gain. In middle-income countries, higher maternal education is significantly associated with elevated WAZ (MD 0.398, 95% CI 0.301-0.496) and HAZ (MD 0.388, 95% CI 0.102-0.673) in children. Similarly, in studies with low-educated population, higher maternal education is significantly linked to increased WAZ (MD 0.186, 95% CI 0.078-0.294) and HAZ (0.200, 95% CI 0.036-0.365). However, in high-income and highly educated population, this association is either absent or reversed. In high-income countries, higher maternal education is associated with a non-significant lower BMI-Z (MD -0.028, 95% CI -0.061 to 0.006). Notably, this inverse association is statistically significant in low-educated populations (MD -0.045, 95% CI -0.079 to -0.011) but not in highly educated populations (MD 0.003, 95% CI -0.093 to 0.098).

Interpretation

Maternal education's association with child growth varies based on country income and education levels. Further research is needed to understand this relationship better.

Funding

This study was a student thesis supported financially by Tehran University of Medical Sciences (TUMS).

Association of Stunting with Socio-Demographic Factors and Feeding Practices among Children under Two Years in Informal Settlements in Gauteng, South Africa

Despite improvements in childhood undernutrition through integrated nutritional programs in South Africa, stunting among children remains persistent, and is attributed to poor socio-demographic status. This context has been implicated in disrupting mothers' decisions regarding effective infant feeding, ultimately meaning that children's nutritional demands remain unmet. In view of this, we conducted a cross-sectional study to determine the association between socio-demographic factors and infant and young child feeding (IYCF) practices and stunting among children under two years receiving primary health care in informal settlements in Gauteng, South Africa. A validated questionnaire was used to assess mothers' socio-demographic status and feeding practices using WHO core indicators. Stunting was defined as length-for age z-scores (LAZ) below -2 standard deviation, computed using WHO Anthro software version 3.2.2.1 using age, sex, and anthropometric measurements of children. Univariate and multivariate analyses were stratified by stunting to determine the relationship with socio-demographic, infant, and IYCF factors using STATA 17. The prevalence of stunting was 16% among surveyed children under two years (with a mean age of 8 ± 5 months) living in poor socio-demographic households. Poor feeding practices were characterized by delayed initiation of breastfeeding (58%), sub-optimal exclusive breastfeeding (29%), discontinued breastfeeding (44%), early introduction of solid foods (41%), and low dietary diversity (97%). Significant differences in terms of child's age, monthly household income, and ever being breastfed were observed (Chi square test and univariate analysis). After controlling for potential confounders, stunting was significantly associated with child's age [12-23 months: AOR = 0.35, 95% CI: 0.16-0.76], and monthly household income [ZAR 3000-ZAR 5000: AOR = 0.47, 95% CI: 0.26-0.86]. Despite the few aforementioned socio-demographic and IYCF factors associated with stunting, this study reiterates stunting as the commonest poor nutritional status indicator among children under two years, suggesting the presence of chronic undernutrition in these poverty-stricken informal settlements. A multisectoral approach to address stunting should be context-specific and incorporate tailor-made interventions to promote optimal infant-feeding practices. Conducting future nutrient assessments focusing on children is imperative.

Risk Factors for Overweight and Obesity within the Home Environment of Preschool Children in Sub-Saharan Africa: A Systematic Review

Sub-Saharan Africa (SSA) is experiencing an increasing prevalence of young children being overweight and obese. Many feeding and physical activity-related behaviours are established at home during preschool years, yet the precise factors that contribute to preschool overweight and obesity have not been fully elucidated. This review aims to identify factors in the home environment associated with overweight and or obesity in preschool children in SSA. Ovid MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, Africa Journals Online (AJOL) and the African Index Medicus databases were systematically searched for qualitative and quantitative studies published between 2000 and 2021. Eleven studies (ten quantitative, one qualitative) met the inclusion criteria. Overall, the results highlight the paucity of studies exploring factors in the home environment associated with overweight and obesity in preschool children in Sub-Saharan Africa. The home food environment and maternal BMI appear to be important factors associated with overweight and obesity in preschool children; however, the information for all other factors explored remains unclear due to the lack of evidence. For successful obesity prevention and treatment interventions to be developed, more research in this area is required to understand how different aspects of the home environment contribute to overweight and obesity in preschool Sub-Saharan African children.

Feeding practices and micronutrient status of children aged 0-36 months in Thulamela Municipality, Limpopo province

BACKGROUND

Micronutrient deficiency continues to be a major public health problem affecting infants and young children under 5 years of age worldwide.

AIM

The study aims to investigate feeding practices and micronutrient status of children aged 0-36 months.

SETTING

The study was conducted at government clinics located in Thulamela Municipality, which is one of the local municipalities in Vhembe District, Limpopo province.

METHODS

A cross-sectional survey was conducted. A total of 250 mothers with children aged 0-36 months were enrolled. A structured questionnaire was used to interview the mothers. Biochemical measurements of children were assessed using standard procedures.

RESULTS

Only 7.6% of children were exclusively breastfed for 6 months. Majority (87.5%) of the children were introduced to complementary foods before 6 months and 98.8% of the children had a low dietary diversity score of less than four, while 9.2% had a dietary diversity score of more than four. The prevalence of vitamin A deficiency, anaemia and iron deficiency was 21.7%, 53.6% and 13.1%, respectively. For mothers who initiated breastfeeding immediately after delivery, the odds of children having low ferritin were 0.11 times, as compared to children who were initiated breastfeeding a day after delivery (odds ratio = 0.11; 95% confidence interval = 0.015-0.812).

CONCLUSION

Most of the children were introduced to complementary foods earlier than 6 months of age. Infant feeding practices were associated with micronutrients status.

CONTRIBUTION

The study contributes to the body of literature on feeding practices and the micronutrient status of children.

Mapping Geographical Differences and Examining the Determinants of Childhood Stunting in Ethiopia: A Bayesian Geostatistical Analysis

Understanding the specific geographical distribution of stunting is essential for planning and implementing targeted public health interventions in high-burdened countries. This study investigated geographical variations in the prevalence of stunting sub-nationally, and the determinants of stunting among children under 5 years of age in Ethiopia. We used the 2016 Ethiopia Demographic and Health Survey (EDHS) dataset for children aged 0–59 months with valid anthropometric measurements and geographic coordinates (n = 9089). We modelled the prevalence of stunting and its determinants using Bayesian geospatially explicit regression models. The prevalence of stunting among children under five years was 36.3% (95% credible interval (CrI); 22.6%, 51.4%) in Ethiopia, with wide variations sub-nationally and by age group. The prevalence of childhood stunting ranged from 56.6% (37.4–74.6%) in the Mekelle Special zone of the Tigray region to 25.5% (10.5–48.9%) in the Sheka zone of the Southern Nations, Nationalities and Peoples region. Factors associated with a reduced likelihood of stunting in Ethiopia included non-receipt of breastmilk, mother’s BMI (overweight/obese), employment status (employed), and higher household wealth, while the enablers were residence in the “arid” geographic areas, small birth size of the child, and mother’s BMI (underweight). The prevalence and determinants of stunting varied across Ethiopia. Efforts to reduce the burden of childhood stunting should consider geographical heterogeneity and modifiable risk factors.

The roles of men and women in maternal and child nutrition in urban South Africa: A qualitative secondary analysis

Industrialization and urbanization processes have challenged deeply held traditional gender norms and facilitated the emergence of modern ideologies in South Africa. This paper seeks to explore the gendered roles of family members on maternal and child nutrition and investigate indications of perceived change in related practices. A qualitative secondary analysis was conducted of data from nine focus group discussions (FGDs) held with men (n = 3) and women (n = 6) aged ≥18. Data from the FGD were coded and thematic analysis conducted. We found that elderly women seem to have a central advisory role with respect to maternal and child nutrition and that men and elderly women upheld patriarchal gender divisions of labour, which entrust mothers with the primarily responsibility for young children's nutrition. Young mothers relied on elderly women for provision of childcare and nutritious foods for children; however, they demonstrated some resistance to traditionally feminized forms of food preparation. We found that men's involvement in children's nutrition was limited, though they expressed a preference to be more involved in maternal and child nutrition and care practices. A gender transformative approach to policy development, which includes elderly women and men, has the potential to promote more gender‐equitable nutrition practices, increase young women's self‐efficacy and support them to overcome barriers that could be limiting their decision making power in achieving optimal nutrition for themselves and their children.

Maternal perspectives on infant feeding practices in Soweto, South Africa

OBJECTIVE

To (i) describe the infant feeding practices of South African women living in Soweto and (ii) understand from the mothers' perspective what influences feeding practices.

DESIGN

Semi-structured focus group discussions (FGD) and in-depth interviews (IDI) were conducted, and data were analysed using thematic analysis.

SETTING

Soweto, South Africa.

PARTICIPANTS

Nineteen mothers were stratified into three FGD according to their baby's age as follows: 0-6-month-olds, 7-14-month-olds and 15-24-month-olds. Four mothers from each FGD then attended an IDI.

RESULTS

Although mothers understood that breast-feeding was beneficial, they reported short durations of exclusive breast-feeding. The diversity and quality of weaning foods were low, and 'junk' food items were commonly given. Infants were fed using bottles or spoons and feeding commonly occurred separately to family meal times. Feeding practices were influenced by mothers' beliefs that what babies eat is important for their health and that an unwillingness to eat is a sign of ill health. As such, mothers often force-fed their babies. In addition, mothers believed that feeding solid food to babies before 6 months of age was necessary. Family matriarchs were highly influential to mothers' feeding practices; however, their advice often contradicted that of health professionals.

CONCLUSIONS

In South Africa, interventions aimed at establishing healthier appetites and eating behaviours in early life should focus on: (i) fostering maternal self-efficacy around exclusive breast-feeding; (ii) challenging mixed feeding practices and encouraging more responsive feeding approaches and (iii) engaging family members to promote supportive household and community structures around infant feeding.

Multi-mycotoxin exposure of children (0-24 months) in rural maize-subsistence farming areas of the Eastern Cape Province, South Africa

In South Africa, child malnutrition is highly prevalent among children from in rural areas mostly at risk. In the Eastern Cape (EC) Province, maize is commonly used as complementary and weaning food. Previous studies conducted in parts of EC have indicated high levels of fumonisin B (FB) mycotoxins in home-grown maize, as well as the co-occurrence of other Fusarium mycotoxins, such as deoxynivalenol (DON) and zearalenone (ZEN). A cross-sectional study of children below 24 months was conducted in rural maize-subsistence farming areas in Centane, EC to determine mycotoxin exposure. Home-grown maize samples (n=171) were collected from households in the study area and analysed by LC-MS/MS for FB, DON and ZEN. Food intakes of 129 children were quantified using a validated quantitative food frequency questionnaire (QFFQ). Individual raw maize consumption was calculated using recipes from the QFFQ. Probable daily intakes (PDIs) for each mycotoxin were determined using a deterministic approach and were compared to the respective mycotoxins’ provisional maximum tolerable daily intake (PMTDI). The numerical means for total FB (sum of fumonisin B1, B2 and B3), DON and ZEN levels in home-grown maize were 1,035, 24.5 and 31.0 μg/kg, respectively. Mean daily maize intakes of children ranged from 2-321 g/day and increased with age. The mean PDIs for total FB, DON and ZEN were 8.4, 0.2 and 0.3 μg/kg body weight (bw)/day, respectively. Exposures stratified by age indicated persistent high mean PDIs for total FB, above the PMTDI of 2 μg/kg bw/day, ranging between 5.0-11.6 μg/kg bw/day. Mean exposure to DON and ZEN were below their relevant PMTDIs (1 and 0.5 μg/kg bw/day, respectively). Individually, 81 and 13% of children had exposures above the PMTDI for total FB and for ZEN, respectively. Results confirm the magnitude of FB exposure among vulnerable groups from rural maize subsistence farming areas in EC.

Social circumstances and cultural beliefs influence maternal nutrition, breastfeeding and child feeding practices in South Africa

BACKGROUND

Maternal and child undernutrition remain prevalent in developing countries with 45 and 11% of child deaths linked to poor nutrition and suboptimal breastfeeding, respectively. This also has adverse effects on child growth and development. The study determined maternal dietary diversity, breastfeeding and, infant and young child feeding (IYCF) practices and identified reasons for such behavior in five rural communities in South Africa, in the context of cultural beliefs and social aspects.

METHODS

The study used mixed methodology technique. Questionnaires were administered to 84 households, pairing mother/caregiver and a child (0-24 months old) to obtain information on maternal dietary diversity, IYCF and breastfeeding practices. Qualitative data on breastfeeding perceptions, IYCF practices, perceived eating habits for lactating mothers and cultural beliefs related to mothers' decision on IYCF and breastfeeding practices were obtained through focus group discussions.

RESULTS

Maternal dietary diversity was very low and exclusive breastfeeding for the first 6 months of life was rarely practiced, with young children exposed to poor-quality diets lacking essential nutrients for child growth and development. Social circumstances including lack of income, dependence on food purchasing, young mothers' feelings regarding breastfeeding and cultural beliefs were the major drivers of mothers' eating habits, breastfeeding behaviour and IYCF practices. Fathers were left out in breastfeeding and IYCF decision making and young mothers were unwilling to employ indigenous knowledge when preparing food (especially traditional foods) and feeding their children.

CONCLUSION

The study provides comprehensive information for South African context that can be used as an intervention measure to fight against malnutrition in young children. Finding a balance between mothers' income, dietary diversity, cultural beliefs, breastfeeding and considering life of lactating mothers so that they won't feel burdened and isolated when breastfeeding and taking care of their children is crucial. Paternal inclusion in breastfeeding decisions and safeguarding indigenous knowledge on IYCF practices is recommended.

Stunting and severe stunting among infants in India: the role of delayed introduction of complementary foods and community and household factors

Background: Delayed introduction of solid, semi-solid or soft foods (complementary feeding) and associated factors are related to stunting and severe stunting among children in many low- and middle-income countries. In India, however, there is limited evidence on the relationship between delayed complementary feeding and associated factors with stunting and severe stunting to advocate for policy interventions.

Objectives: The present study investigated the relationship between delayed complementary feeding and associated factors with stunting and severe stunting among infants aged 6–8 months in India.

Methods: Survey data on 13,548 infants aged 6–8 months were obtained from the 2015–16 National Family Health Survey in India. Logistic regression (Generalized Linear Latent and Mixed Models [GLLAMM] with a logit link and binomial family) models that adjusted for clustering and sampling weights were used to investigate the relationship between delayed complementary feeding and associated factors (community, household, maternal, child and health service factors) with stunting and severe stunting among infants aged 6–8 months in India.

Results: The prevalence of stunting and severe stunting was 22.0% (95% CI: 21.0–23.7%) and 10.0% (95% CI: 9.0–11.0%) among infants aged 6–8 months who received no complementary foods, respectively. Delayed introduction of solid, semi-solid or soft foods was associated with stunting (adjusted Odd ratios [aOR] = 1.24, 95% CI: 1.09–1.41) and severe stunting (aOR = 1.21, 95% CI: 1.01–1.45) among infants aged 6–8 months. High maternal education (secondary or higher education) and household wealth (middle, richer and richest) were protective against stunting and severe stunting.

Conclusion: Delayed introduction of complementary foods and associated factors were related to stunting and severe stunting among infants aged 6–8 months in India. Reducing the proportion of infants who are stunted in India would require comprehensive national nutrition policy actions that target the sub-population of mothers with no schooling and limited resources.

The association between household socio-economic status, maternal socio-demographic characteristics and adverse birth and infant growth outcomes in sub-Saharan Africa: a systematic review

Adverse birth outcomes and infant undernutrition remain the leading causes of morbidity and mortality in sub-Saharan Africa (SSA). Impaired infant growth and development, which often begins during foetal development, may persist during the first 2 years of life and has been associated with higher risks of cardiometabolic diseases. This systematic review assessed the associations between maternal demographic characteristics and household socio-economic status (SES), and preterm birth (PTB), small for gestational age, low birth weight (LBW), stunting, wasting and underweight in children under 2 years of age in SSA countries. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched for publications in three electronic databases (PubMed, Scopus and ScienceDirect). Eleven studies on children under 2 years of age, in four SSA regions, published in English between 1990 and 2018, were included. All the studies were observational in design (cross-sectional or cohort studies). Maternal education was the most commonly explored exposure. Most studies (63.3%) focused on undernutrition during the first 2 years of life: LBW, PTB and stunting. Lower maternal education, maternal unemployment and lower household wealth index were the SES factors most commonly associated with adverse birth outcomes and infant undernutrition. Maternal marital status was not associated with any infant outcomes. The definitions of the SES varied, which may explain discrepancies between studies. Nutrition intervention programs in SSA need to promote education and poverty alleviation in women at reproductive age, starting from pre-pregnancy, to optimise infant growth and development and prevent the increase in the prevalence of cardiometabolic diseases.

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review

BACKGROUND

In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.

OBJECTIVES

The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.

METHODS

We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.

RESULTS

From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.

CONCLUSIONS

From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

Factors associated with exclusive breastfeeding practice in a cohort of women from Cali, Colombia

Introduction:

Breastfeeding promotion is one of the most effective strategies to prevent child malnutrition; it reduces costs to families, health services and society. In Colombia, exclusive breastfeeding is practiced only by 10% of women.

Objective:

To identify factors associated with the duration of exclusive breastfeeding.

Methods:

A cohort of 438 primiparous women was followed during 6 months by means of 8 home interviews, in order to determine the duration of exclusive breastfeeding. Individual, family and health service factors were studied; and survival analysis was carried out.

Results:

At 8 days, only a few more than half of the participants maintained exclusive breastfeeding; at month 6 of follow-up, this proportion was reduced to 1.4%. The duration of exclusive breastfeeding was determined by: initiation of breastfeeding in the first 4 hours after delivery (HR= 4.07, 95% CI: 0.96-16.67), self-perceived sureness for breastfeeding (HR= 1.28, 95% CI: 1.04 -1.58), positive opinion of the baby's father regarding breastfeeding (HR= 1.26, 95% CI: 1.01-1.57), and newborn weight (HR= 1.23, 95% CI: 1.00-1.53).

Conclusion:

There are factors before delivery and in the immediate puerperium that determine, partially, the duration of exclusive breastfeeding.

Beyond health care providers' recommendations: understanding influences on infant feeding choices of women with HIV in the Eastern Cape, South Africa

Background

Despite the array of studies on infant feeding practices of HIV-infected women, gaps still exist in the understanding of the underlying reasons for their infant feeding choices. Potential for behavioural change exists, especially in the light of the 2016 updated World Health Organization guideline on HIV and infant feeding. The aim of this paper is to determine the rate of adoption of exclusive breastfeeding in this cohort, examine the determinants of infant feeding choices of HIV-infected women and assess the underlying reasons for these choices.

Methods

This was a mixed methods study conducted between September 2015 and May 2016. It analyses the quantitative and qualitative data of 1662 peripartum women enrolled in the East London Prospective Cohort Study across three large maternity services in the Eastern Cape. Women with HIV reported their preferred choices of infant feeding. In addition, participants explained the underlying reasons for their choices. Descriptive and inferential statistics summarised the quantitative data, while thematic content analysis was performed on qualitative data.

Results

Of the 1662 women with complete responses, 80.3% opted to exclusively breastfeed their babies. In the adjusted model, up to grade 12 education level (AOR: 1.81; 95% CI: 1.14, 2.86), rural/peri-urban residence (AOR:1.44; 95% CI: 1.05, 1.96), alcohol use (AOR: 1.65; 95% CI: 1.25, 2.18), negative or unknown HIV status at booking (AOR:1.85; 95% CI:1.27, 2.70), currently married (AOR:1.43; 95% CI:1.01, 2.02) and WHO Clinical Stage 2–4 (AOR:1.77; 95% CI: 1.15, 2.72) were significantly associated with the decision to exclusively breastfeed. Health care providers’ recommendations, perceived benefits of breastfeeding, unaffordability of formula feeding, and coercion were the underlying reasons for wanting to breastfeed; while work/school-related demands, breast-related issues, and fear of infecting the baby influenced their decision to formula feed.

Conclusion

The majority of HIV-infected women chose to breastfeed their babies in the Eastern Cape. Following up on these women to ensure they breastfeed exclusively, while also addressing their possible concerns, could be an important policy intervention. Future studies should focus on how early infant feeding decisions change over time, as well as the health outcomes for mother and child.

Risk of Exposure to Multiple Mycotoxins from Maize-Based Complementary Foods in Tanzania

This study estimated exposure to multiple mycotoxins in 249 infants aged between 6 and 12 months in three agro-ecological zones of Tanzania. Maize-based complementary food intakes were estimated using two 24 h dietary recalls. Using @Risk software, probabilistic exposure assessment was conducted by modeling maize intake data (kg/kg body weight/day) with previously determined multiple mycotoxin (except for ochratoxin A (OTA) and zearalenone (ZEA), present in only a few samples) contamination data (μg/kg) in maize. Maize intakes ranged from 0.13 to 185 g/child/day (average = 59 ± 36 g/child/day). The estimated mean exposures were higher for aflatoxins (6-fold), fumonisins (3-fold), and deoxynivalenol (2-fold) than health-based guidance values of 0.017 ng/kg body weight/day, 2 μg/kg body weight/day, and 1 μg/kg body weight/day, respectively. The population at risk of exposures above the limits of health concern ranged from 12% for HT-2 toxin through 35% for deoxynivalenol to 100% for aflatoxins. The exposure varied among the agro-ecological zones. Strategies targeting multiple mycotoxins in maize are urgently needed to minimize exposures in Tanzania.

Infant feeding practices in a South African birth cohort-A longitudinal study

Childhood malnutrition is highly prevalent in low- and middle-income countries. The choices of complementary foods, which are important in infant nutrition, are poorly described in this setting. We investigated infant feeding practices in a South African birth cohort, the Drakenstein Child Health Study. Longitudinal feeding data were collected from March 2012 to March 2015. Feeding practices at birth, 6-10 and 14 weeks and 6, 9, and 12 months, were investigated using food frequency questionnaires. Anthropometry was measured at birth and 12 months. The quality of the diet was analyzed using the World Health Organization infant and young child feeding indicators. Regression models were used to explore associations between feeding and growth outcomes at 1 year. Exclusive breastfeeding for 6 months was low (13%), and 19% of infants were introduced to solid foods before 4 months. There was high daily consumption of processed meat (56%) and inappropriate foods such as fruit juice (82%), soft drinks (54%), and refined sugary foods (51%) at 1 year. Dietary diversity and consumption of iron rich foods were low at 6 months (5% and 3%, respectively) but higher by 12 months (75% and 78%). Longer duration of exclusive breastfeeding was associated with a lower height-for-age z-score at 1 year. Several dietary deficits and a rising trend in the consumption of inappropriate nutritionally poor foods were identified. These findings raise concern about poor dietary practices and the impact on child and long-term health.

Iodine status and associations with feeding practices and psychomotor milestone development in six-month-old South African infants

Iodine is important for normal growth and psychomotor development. While infants below 6 months of age receive iodine from breast milk or fortified infant formula, the introduction of complementary foods poses a serious risk for deteriorating iodine status. This cross-sectional analysis assessed the iodine status of six-month-old South African infants and explored its associations with feeding practices and psychomotor milestone development. Iodine concentrations were measured in infant (n = 386) and maternal (n = 371) urine (urinary iodine concentration [UIC]), and in breast milk (n = 257 [breast milk iodine concentrations]). Feeding practices and psychomotor milestone development were assessed in all infants. The median (25th-75th percentile) UIC in infants was 345 (213-596) μg/L and was significantly lower in stunted (302 [195-504] μg/L) than non-stunted (366 [225-641] μg/L) infants. Only 6.7% of infants were deficient. Maternal UIC (128 [81-216] μg/L; r_s  = 0.218, p < 0.001) and breast milk iodine concentrations (170 [110-270] μg/kg; r_s  = 0.447, p < 0.0001) were associated with infant UIC. Most infants (72%) were breastfed and tended to have higher UIC than non-breastfed infants (p = 0.074). Almost all infants (95%) consumed semi-solid or solid foods, with commercial infant cereals (60%) and jarred infant foods (20%) being the most common solid foods first introduced. Infants who reported to consume commercial infant cereals ≥4 days weekly had significantly higher UIC (372 [225-637] μg/L) than those reported to consume commercial infant cereals seldom or never (308 [200-517] μg/L; p = 0.023). No associations between infant UIC and psychomotor developmental scores were observed. Our results suggest that iodine intake in the studied six-month-old infants was adequate. Iodine in breast milk and commercial infant cereals potentially contributed to this adequate intake.

Association of 6 months of exclusive breastfeeding with higher fat-free mass in infants in a low-resource setting with high HIV prevalence in South Africa

Exclusive breastfeeding for 6 months is recommended by the World Health Organisation (WHO) for optimal health and growth of infants, but it is not a common practice in South Africa. A breastfeeding counselling programme was run to inform, encourage and support mothers to exclusively breastfeed their infants for 6 months, and mother-infant pairs were invited to participate in a research project to determine breast milk intake volumes using the dose-to-mother deuterium dilution stable isotope technique. This technique yields objective measurements of breast milk intake volumes and also enables determination of exclusivity of breastfeeding, which is most frequently determined by maternal recall and can be subject to bias. Exclusivity of breastfeeding at 6 weeks, 3 months and 6 months following birth of the infants was correlated with infant fat-free mass at 12 months, which was determined by the dose-to-infant deuterium dilution stable isotope technique. Results showed that infants who were exclusively breastfed for 6 months had a higher per cent fat-free mass at 12 months compared with infants who were not exclusively breastfed for 6 months (P < 0.05). This objective determination of both breastfeeding patterns and infant body composition gives weight to the WHO recommendation of exclusive breastfeeding for 6 months as it demonstrated adequate fat-free mass in infants at 12 months, even in an area with high HIV prevalence. © 2016 John Wiley & Sons Ltd.

Poor dietary diversity and low nutrient density of the complementary diet for 6- to 24-month-old children in urban and rural KwaZulu-Natal, South Africa

Infants and toddlers have high nutritional requirements relative to body size but consume small amounts of food and therefore need nutrient-dense complementary foods. A cross-sectional study included children aged 6-24 months, stratified in three age categories (6-11 months, 12-17 months and 18-24 months) and randomly selected from an urban (n = 158) and a rural (n = 158) area, both of low socio-economic status, in the KwaZulu-Natal Province of South Africa. Dietary diversity and nutrient density of the complementary diet (excluding breast milk and formula milk) based on a repeated 24-h dietary recall was assessed. For breastfeeding children, nutrient density of the complementary diet was adequate for protein, vitamin A and vitamin C; and inadequate for 100% of children for zinc, for >80% of children for calcium, iron and niacin; and between 60% and 80% of children for vitamin B6 and riboflavin. Urban/rural differences in density for animal and plant protein, cholesterol and fibre occurred in 18-24-month-old children. Fewer than 25% of children consumed ≥4 food groups, with no urban/rural differences. Higher dietary diversity was associated with higher nutrient density for protein and several of the micronutrients including calcium, iron and zinc. The poor nutrient density for key micronutrients can probably be ascribed to lack of dietary variety, and little impact of mandatory fortification of maize meal/wheat flour on infants/toddlers' diet. Targeted strategies are needed to enable mothers to feed their children a more varied diet.

Determinants of Stunting and Overweight among Young Children and Adolescents in Sub-Saharan Africa

Background

Stunting and overweight are nutritional problems affecting most of sub-Saharan Africa. The region now has the world's highest rate of stunting among children (43%), while overweight and obesity are becoming a global epidemic, and Africa is not spared. The past two decades have seen a dramatic increase in obesity in sub-Saharan Africa.

Objective

The purpose of this systematic review is to explore the determinants of stunting and overweight in sub-Saharan Africa.

Methods

A literature search was conducted in PubMed using the key words stunting, overweight, obesity, Africa, sub-Saharan Africa, determinants, and prevalence. Limits were set to include articles published between 1990 and 2012. The systematic review resulted in 38 studies, and after selection based on title, content, and country of the study, 18 studies were eligible for this review. Data were analyzed by the chi-square test.

Results

The prevalence rates of stunting and over-weight were dependent on socioeconomic, demographic, and environmental factors. Many studies indicate that male children and those living in a rural setting are more likely to be stunted, whereas overweight among children depends more on age, household composition, occupation of the mother, and the mother's body mass index. Stunting occurred together with overweight among both boys and girls from 1 to 5 years of age. Stunting was more prevalent among boys than among girls. Indicators of socioeconomic status, such as mother's education, mother's occupation, and household income, were some of the determinants directly linked to stunting, whereas environmental factors, such as rural or urban setting and sanitation, influenced both stunting and overweight. Concurrent stunting and overweight is influenced by maternal and household factors, such as maternal height, age, and education, large household size, and lower socioeconomic status.

Conclusions

Although socioeconomic, demographic, and environmental factors were significant in determining stunting and overweight, other factors, such as nutrition and lifestyle, were important risk factors. Stunting in childhood is a risk factor that may result in overweight and obesity later in adolescence and adulthood, indicating the need to screen children below 1 year of age to identify stunting early in life. Promoting exclusive breastfeeding is reported to be important in preventing both stunting and overweight among children. More research is needed to explore the relationship between stunting and overweight and to explore policy guidelines to address the phenomenon.

Methods to quantify soft tissue-based cranial growth and treatment outcomes in children: a systematic review

Context

Longitudinal assessment of cranial dimensions of growing children provides healthcare professionals with information about normal and deviating growth as well as treatment outcome.

Objective

To give an overview of soft tissue–based methods for quantitative longitudinal assessment of cranial dimensions in children until age 6 years and to assess the reliability of these methods in studies with good methodological quality.

Data source

PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched. A manual search was performed to check for additional relevant studies.

Study selection

Primary publications on facial growth and treatment outcomes in children younger than age 6 years were included.

Data extraction

Independent data extraction was performed by two observers. A quality assessment instrument was used to determine methodological quality. Methods used in studies with good methodological quality were assessed for reliability expressed as the magnitude of the measurement error and the correlation coefficient between repeated measurements.

Results

In total, 165 studies were included, forming three groups of methods: head circumference anthropometry, direct anthropometry, and 2D photography and 3D imaging techniques (surface laser scanning and stereophotogrammetry). In general, the measurement error was below 2 mm, and correlation coefficients were very good.

Conclusion

Various methods for measuring cranial dimensions have shown to be reliable. Stereophotogrammetry is the most versatile method for quantitative longitudinal assessment of cranial dimensions and shapes in children. However, direct anthropometry continues to be the best method for routine clinical assessments of linear cranial dimensions in growing children until age 6 years.

Prevalence of anaemia and its associated factors in African children at one and three years residing in the Capricorn District of Limpopo Province, South Africa

Objective: The present study evaluated the prevalence of anaemia and its determinants in one- and three-year-old children from the Capricorn District of Limpopo Province, South Africa. Methods: A prospective cohort study conducted in rural villages in the Capricorn District of Limpopo Province, South Africa. At birth, a cohort of 219 children was followed until they were one and three years of age. Data collected included the children’s anthropometric measurements, blood for biochemical analysis (full blood count, ferritin, folate and vitamin B12) and socio-demographic status.Results: At one year, anaemia (Hb < 11 g/dL) was present in 52% of the children, decreasing to 22% by the third year. Iron deficiency (ferritin < 12 µg/mL) was common in these children (39% and 33% at one year and three years, respectively) particularly in the presence of anaemia. Folate and vitamin B12 deficiencies (< 5 ng/mL and < 145 pg/mL, respectively) were common at one year, with the children accumulating enough vitamin B12 by three years; however, folate deficiency levels remained fairly constant between the two time points.Conclusion: There was a high prevalence of anaemia in the study participants at one year and three years of age. Factors that increased the risk of anaemia at three years were: a mother with only a primary school education, anaemia at one year, male gender, overweight, and combined overweight and stunting. Protective factors against anaemia were having a younger mother who served as the main caregiver.

Identifying important life stages for monitoring and assessing risks from exposures to environmental contaminants: results of a World Health Organization review

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We propose a harmonized set of age bins for assessing risks from chemical exposure.

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The set of early life age groups will facilitate consistency with recent guidance.

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The age bins allow results from longitudinal birth cohort studies to be combined.

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Region-specific exposure factors and monitoring data are needed to apply the bins.

In this paper, we summarize exposure-related issues to consider in determining the most appropriate age ranges and life stages for risk assessment. We then propose a harmonized set of age bins for monitoring and assessing risks from exposures to chemicals for global use. The focus is on preconception through adolescence, though the approach should be applicable to additional life stages. A two-tiered set of early life age groups is recommended. The first tier involves the adoption of guidance similar to the childhood age groups recommended by the U.S. Environmental Protection Agency, whereas the second tier consolidates some of those age groups to reduce the burden of developing age-specific exposure factors for different regions. While there is no single “correct” means of choosing a common set of age groups to use internationally in assessing early life exposure and risk, use of a set of defined age groups is recommended to facilitate comparisons of potential exposures and risks around the globe, the collection of data and analyses of aggregate exposure and cumulative risk. Application of these age groups for robust assessment of exposure and risk for specific populations will require region-specific exposure factors as well as local environmental monitoring data.

Effects of exclusive breastfeeding intervention on child growth and body composition: the MINIMat trial, Bangladesh

AIM

Exclusive breastfeeding (EBF) for 6 months is recommended for optimal infant health, but the evidence for longer-term impacts is weak. We examined whether randomization to receive EBF counselling (BFC) in rural Bangladeshi women had an impact on childhood growth trajectories and body composition.

METHODS

In the Maternal and Infant Nutrition Interventions in Matlab trial, 4436 pregnant women were randomized to six equally sized, food and micronutrient groups. Of these, 3214 were randomized during the last trimester of pregnancy to receive either BFC or the usual/standard health message (UHM). Their infants were extensively followed up, with anthropometric measurements between 0 and 54 months and assessment of body composition at 54 months.

RESULTS

The mean duration of EBF in the BFC group was 111 days compared to 76 days in the UHM group (mean difference: 35.0 days, 95% CI 30.6-39.5, p < 0.001). There was no difference in growth trajectories between the BFC and UHM groups and no difference in body composition at 54 months. Children exposed to prenatal multiple micronutrients (vs 60 mg iron and folate) combined with BFC (vs UHM), however, had slower linear growth (mean difference -0.17 SD score, p < 0.01).

CONCLUSION

Exclusive breastfeeding counselling resulted in neither differential growth trajectories in infancy and childhood, nor body composition differences at 54 months. The combination of prenatal multiple micronutrient supplementation (MMS) and BFC was unfavourable for linear growth during 0-54 months, which raises questions about possible negative effects of MMS.

Pattern and characteristics of growth faltering in early infancy in an urban sub-Saharan African setting

OBJECTIVE

To determine the pattern of and factors associated with changes in nutritional status in early infancy in a resource-poor setting.

METHODS

A cohort study in Lagos, Nigeria, in which the nutritional status at birth was compared with status at the first postnatal check-up routinely scheduled for 6-8 weeks based on the World Health Organization's multicenter growth reference and the Centers for Disease Control and Prevention 2000 growth charts. Factors associated with improved, worsened or steady nutritional status at follow-up based on z-scores for weight-for-age, length-for-age and weight-for-length were determined with multinomial regression analysis.

RESULTS

The mean length-for-age and weight-for-length based on the Centers for Disease Control and Prevention for the 445 full-term singletons studied were higher than the corresponding World Health Organization's multicenter growth reference values at birth and at follow-up, while mean weight-for-age was lower at birth but higher subsequently. Some 20.7% of infants were undernourished by at least one nutritional measure initially, which declined to 16.4% at follow-up. Also 8.1% of the infants remained undernourished, 8.3% became undernourished, and 5.6% became well-nourished at follow-up. Low birthweight full-term infants were significantly likely to remain undernourished (p < 0.001) or become well-nourished (p < 0.001) at follow-up while the offspring of elderly mothers (p = 0.024) or first-time mothers (p = 0.036) had an elevated risk of remaining undernourished by at least one measure at follow-up.

CONCLUSIONS

Many infants are likely to exhibit individual nutritional changes at variance with the overall/summary trend. Those whose nutritional status is likely to deteriorate or remain poor require timely intervention to minimize the risk of subsequent developmental delays/deficits from early infancy.

Food insecurity is associated with attitudes towards exclusive breastfeeding among women in urban Kenya

This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)-affected and 75 HIV-status unknown, low-income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open-ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV-affected and HIV-status unknown mothers (n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low-income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months.

Predictors of growth velocity in early infancy in a resource-poor setting

OBJECTIVE

To determine the pattern and predictors of growth velocity in early infancy in a resource-poor setting.

METHODS

Weight velocity between birth and first postnatal visit was determined in a cohort of preterm and full-term infants in Lagos, Nigeria using three mathematical methods reported in the literature. Maternal and infant factors predictive of weight velocity were identified by multiple linear regression analysis.

RESULTS

Overall, 658 infants were enrolled with mean gestational age of 37.7±2.0 weeks, birthweight of 3.2±0.6 kg and median age of 45 (interquartile range: 42-48) days at follow-up. Offspring of older and HIV-positive mothers had significantly lower mean weight velocities while male infants and those with low birthweight and fetal growth restriction had significantly higher mean weight velocity than their peers. These patterns were consistent across the three growth models. Maternal age (p=0.004), antenatal care (p=0.007), HIV-status (p=0.008) and gender (p<0.001) were predictive of weight velocity. Higher weight velocity was strongly associated with lower birthweight (p<0.001) indicative of "catch-up" growth as well as with higher gestational age (p<0.001).

CONCLUSIONS

While maternal status is predictive of early growth faltering, preterm infants warrant timely intervention to forestall/minimise the potential health and developmental consequences associated with their sub-optimal growth trajectory.

Breast vs. bottle: differences in the growth of Croatian infants

The aim of the paper was to compare the growth of rural Croatian infants with 2000 Centers for Disease Control and Prevention (CDC) growth standards and to evaluate the potential preventive influence of breastfeeding on the development of obesity in infancy. Two hundred three infant-mother pairs from Baranja, an Eastern region of Croatia, were enrolled into this study. Retrospective evaluation of infants' medical charts was used to obtain anthropometric data recorded at the birth, 1, 3, 6, 9 and 12 months of age. Infant feeding mode was self-reported by mothers. Breastfed infants gained the least weight of all observed groups. Up to 6 months of age, formula fed infants had the highest weight gain and after 6 months of age, mixed milk fed infants had the highest weight gain. At 12 months of age, 6.4% of all study infants and 7.6% of mixed milk fed infants were at risk of overweight, while the same risk for the group of breastfed infants was 4%. Most of the study infants achieved higher values of body mass and length than the child growth standards. Exclusively breastfed infants, in comparison with other study groups (formula fed infants, mixed milk fed infants and cow's milk fed infants), had lower weight-for-length z-scores during the first year, which suggests that breastfeeding may have a preventive impact on obesity development.

Diverging opinions of supplementation programmes between mothers of small children and staff at primary health clinics in the Western Cape Province of South Africa

OBJECTIVE

Nutritional status has remained inadequate among disadvantaged mothers and small children in South Africa. Several supplementation programmes are administered through primary health clinics (PHC). The present study examined the perceptions of mothers who attend PHC and of the PHC staff on the purpose, management and eligibility of the vitamin A and nutritional supplementation components of the Nutrition Supplementation Programme (NSP).

DESIGN

Observational study based on anthropometry and questionnaires.

SETTING

Random selection of ten urban and ten rural PHC from the Western Cape Province of South Africa.

SUBJECTS

Mothers (n 176) and their children (n 179) aged <5 years, and various PHC staff categories.

RESULTS

Half (56 %) of the households were classified as food insecure and about one-third of the children were malnourished, as evidenced by stunting, wasting or underweight. A majority of mothers complained about poor information related to the programmes. More than half of the children who were eligible for NSP were not included. In contrast, the staff felt that they managed both programmes well and problems with implementation were mostly attributed to clients.

CONCLUSIONS

In general, the mothers expressed more dissatisfaction and ignorance about the vitamin A programme and the NSP than was perceived by the staff. This apparent discrepancy might, at least in part, explain why these programmes do not work optimally.

Prevalence, pattern and risk factors for undernutrition in early infancy using the WHO Multicentre Growth Reference: a community-based study

This cross-sectional study set out to determine the prevalence, pattern and risk factors for undernutrition during early infancy in a setting with substantial non-hospital births against the backdrop of limited evidence on nutritional status in the first three months of life based on an exclusively breast-fed reference population. Undernutrition based on z-scores below -2 for weight-for-age, height/length-for-age and body-mass-index-for-age among infants (0-3 months) attending clinics for routine Bacille de Calmette-Guérin (BCG) immunisation in Lagos, Nigeria from July 2005 to March 2008 was determined using current World Health Organisation's Multicentre Growth Reference (WHO-MGR). Maternal and infant factors associated with undernutrition were explored with multivariable logistic regression analyses. Of the 5888 full-term infants enrolled 51% were born outside hospital and 99.4% were exclusively breast-fed. 811 (13.8%) were underweight (weight-for-age), 1802 (30.8%) were stunted (height/length-for-age) and 579 (10.0%) were wasted (body-mass-index-for-age). Altogether, 3635 (61.6%) infants were not undernourished while 192 (3.3%) were undernourished by all three nutritional measures. Intrauterine growth restriction was a significant contributor to undernutrition. Maternal age, multiple pregnancies and gender were associated with all nutritional indices. Additionally, maternal education, ownership/type of residence, parity, antenatal care, place of delivery and hyperbilirubinaemia were predictive of underweight, stunting and wasting. We conclude that undernutrition is prevalent in the first three months of life in this population and can be detected early at routine immunisation clinics shortly after birth. Maternal/perinatal history offers valuable predictors in resource-poor communities where the majority of births occur outside hospital.

Breastfeeding practices among Jordanian women

The purpose of the study was to explore Jordanian women's breastfeeding beliefs and practices including exclusive breastfeeding. A descriptive cross-sectional design with a convenience sample of 200 Jordanian mothers was used. The majority of mothers were muliparous and were recruited from primary health-care centres within 6 weeks of a normal vaginal birth or an instrumental delivery. Eligible women, who met the inclusion criteria, were invited to participate in the study. A sociodemographic data form and a 14-item questionnaire concerning different aspects of breastfeeding beliefs and practices were developed for self administration. This study indicated high early initiation of breastfeeding. Most mothers gave supplements other than breastfeeding, including water without knowing that this supplementation could affect exclusive breastfeeding or the continuation of breastfeeding. Finding of this study shed some light on the current breastfeeding practices including exclusive breastfeeding among Jordanian women. Women need to be better educated about breastfeeding. Therefore, more efforts and resources should be put into providing opportunities for education to discuss breastfeeding during antenatal care. This Jordanian study could be relevant to Arabic women in the West, because cultural beliefs and practices are likely to be part of immigrant woman's perceptions about breastfeeding practices.

Nutritional status of under-five children in libya; a national population-based survey

Aim

To describe the nutritional status of children under-five years of age in Libya.

Population and methods

A secondary analysis of data of 5348 children taken from a national representative, two-stage, cluster-sample survey that was performed in 1995. Results: Prevalence rates of underweight, wasting, stunting, and overweight were determined using standard definitions in reference to newly established WHO growth charts. The study revealed that 4.3% of children were underweight, 3.7% wasted, 20.7% stunted, and 16.2% overweight. Seventy percent of children had normal weight. Undernutrition was more likely to be found in males, in rural areas, and in underprivileged groups. Overweight was more likely found in urban, privileged groups. Wasting was more common in arid regions; stunting was more common in mountainous regions of Al-Akhdar, Al-Gharbi, and in Sirt. Al-Akhdar had the highest prevalence of overweight.

Conclusion

The country had a low prevalence of underweight and wasting, moderate prevalence of stunting, and high prevalence of overweight. The country is in the early stages of transition with evidence of dual-burden in some regions. Similar surveys are needed to verify secular trends of these nutritional problems, particularly overweight.

WHO 2006 child growth standards: implications for the prevalence of stunting and underweight-for-age in a birth cohort of Gabonese children in comparison to the Centers for Disease Control and Prevention 2000 growth charts and the National Center for Health Statistics 1978 growth references

OBJECTIVES

To assess the proportion of children being stunted and underweight-for-age at 3, 9 and 15 months in Lambaréné, Gabon, using the WHO child growth standards released in 2006 as compared with the Centers for Disease Control and Prevention (CDC) 2000 and the National Center for Health Statistics (NCHS) 1978 child growth charts/references.

DESIGN AND SETTING

Prospective birth cohort in Lambaréné, Gabon.

SUBJECTS

Two hundred and eighty-nine children from birth to 15 months of age.

METHODS

Weight and length were recorded at 3, 9 and 15 months. Corresponding Z scores for stunting and underweight-for-age were calculated for the three different standards/references. Children with a height-for-age or weight-for-age below -2 SD of the corresponding reference median (Z score < or = -2) were classified as stunted or underweight-for-age, respectively.

RESULTS

With the new WHO 2006 standards a higher proportion (4.0%) of 3-month-old infants were underweight compared with the CDC (1.0%) or the NCHS (0.7%) child growth charts/references. In contrast to the NCHS references or the CDC charts, this proportion did not increase from 3 to 9 months or from 9 to 15 months. The proportion of children being stunted was highest (above 20%) with the WHO 2006 standards at all three ages. Again, in contrast to the old standards, this proportion did not increase from 3 to 9 months or from 9 to 15 months.

CONCLUSIONS

The present results show considerably different growth faltering patterns for Gabonese children depending on the growth charts used to assess the prevalence of stunting and underweight. Shifting to the new WHO child growth standards may have important implications for child health programmes.

Optimizing the introduction of complementary foods in the infant's diet: a unique challenge in developing countries

Being one of a series of technical support papers pertaining to the South African paediatric food-based dietary guidelines, this paper specifically deals with two of the guidelines proposed for the age group 6-12 months regarding the introduction of complementary foods in the infant's diet. Studies have shown that most of South African infants receive solid foods at the age of 4 months or earlier while only a small percentage are breastfed exclusively until 6 months. The untimely and inappropriate introduction of complementary foods have been shown to be risk factors for both under- and over-nutrition with resultant under- or overweight, stunting and micronutrient deficiencies. Optimal timing for the introduction of complementary foods will depend on the infant's physiological and developmental status. Small, frequent meals of easily digestable, smooth, semisolid nutrient- and energy-dense complementary foods should initially be offered while gradually increasing variety in both the type and texture of food. Protein and carbohydrate intake should increase with the infant's age while preference should be given to foods rich in micronutrients. It should be observed that certain foods, such as fresh cow's milk and egg white, because of their allergenic properties, as well as fat-free and high-fibre foods, excessive fruit juice and low nutrient value drinks such as tea are not recommended. Timely introduction of appropriate complementary foods is vital for the immediate and long-term health of the infant and caregivers should be accordingly advised on feeding at this age.

Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women

AIM

The purpose of this study was to determine the factors that affect exclusive breastfeeding of healthy babies aged 0-4 months.

BACKGROUND

Both the World Health Organization (WHO) and UNICEF recommend feeding babies of 0-6 months exclusively with breast milk and starting complementary foods after the sixth month. In Turkey, however, a vast majority of babies 1-5 months of age (89.4%) are given complementary foods.

METHODS

This cross-sectional study was conducted in central Ankara province, with a sampling of 514 individuals who were selected using the convenience sampling method.

RESULTS

Of the 514 mothers who participated in my research, 260 (50.6%) were found to be feeding their babies exclusively with breast milk; 77 (15.0%), with breast milk + water; 87 (16.9%), with breast milk + baby formula; 70 (13.6%), with breast milk + baby formula + other foods; and 20 (3.9%), baby formula + other foods. Based on multivariate logistic regression analysis results, the mother's employment [odds ratio (OR) = 0.488; 95% confidence interval (CI) = 0.288-0.827) considerably reduced the incidence of complementary foods, while frequent crying of the baby (OR = 1.687; 95% CI = 1.125-2.530) significantly increased the use of supplementary foods in infant nutrition.

CONCLUSION

This study concluded that frequent crying of the baby increases the likelihood of giving the baby complementary foods. Midwives and nurses can encourage exclusive breastfeeding behaviour by providing individual education and counselling to women whose babies cry frequently.

RELEVANCE TO CLINICAL PRACTICE

Exclusive breastfeeding of babies aged 0-6 months is crucial for the development and growth of the baby and instrumental in reducing infant morbidities and mortalities. One factor that increases the likelihood of provision of complementary foods is frequent crying of the baby. Midwives and nurses can encourage exclusive breastfeeding behaviour by providing individual education and counselling to women whose babies cry frequently.

An assessment of preliminary food-based dietary guidelines for infants 6–12 months of age in the Little Karoo area of the Western Cape Province of South Africa

Objective

This study aimed to assess mother's/caregiver's understanding, practical application and cultural acceptability of a preliminary set of South African food-based dietary guidelines (FBDGs) for children aged 6–12 months living in the Little Karoo area of the Western Cape Province.

Design

An observational, descriptive and cross-sectional study design was followed. Focus group interviews, recorded on videotape, were analysed for qualitative data. Quantitative questionnaires measured knowledge and comprehension of guidelines, perceived constraints to compliance with and importance of guidelines as well as socio demographic data prior to the focus group interviews.

Setting

Afrikaans-, English- and Xhosa-speaking communities of the Little Karoo area of the Western Cape Province of South Africa, including the urban areas of Oudtshoorn, Bongulethu, Bridgton, Toekomsrus and the adjacent rural areas of Dysselsdorp, Calitzdorp, Uniondale, Ladismith and Zoar.

Subjects

Sixty-four mothers or caregivers to infants 6–12 months of age were included in the sample.

Results

Information obtained through the questionnaires supported what was said during discussions. Although perceived as important by the majority of respondents, some of the guidelines were not well understood without prior explanation. Such guidelines were those pertaining to meal frequency and cup feeding, while application of the guideline to prolonged breast-feeding seemed the most problematic.

Conclusions

The FBDGs for this age group will have to be supported by extensive and appropriate educational material to be effective when introduced to the public. The fact that the applicability of the guideline to prolonged breast-feeding seemed to be the most problematic is a cause for concern.

The social context of children's nutritional status in rural South Africa

AIM

To investigate the relationship between children's nutritional status and a series of measures capturing both the current status and the lifetime history of their connection with adult caregivers in the Agincourt sub-district of rural South Africa.

METHODS

Using data on a sample of 202 children from a recent ethnographic study of children's social connections and well-being, the authors (1) compare height for age and weight for age to an accepted international standard and (2) conduct bivariate analyses of the relationships between selected measures of social connection and extreme deviations below expected weight and expected height.

RESULTS

Fitted curves for weight for age and height for age fall between the 5th and 50th percentiles of CDC growth curves. Compromised nutrition, defined as being more than two standard deviations below expected height or weight, is associated with the death or non-co-residence of the mother, and with the absence of financial support from the father. The co-residence of maternal female kin as substitutes for the mother do not fully compensate for her absence.

CONCLUSIONS

The findings highlight the importance of parental living arrangements, parental financial support, birth order and the composition of sibling sets, and lifetime residential patterns in facilitating access to nutrition.

Association between insulin-like growth factor-1, insulin-like growth factor-binding protein-1 and leptin levels with nutritional status in 1–3-year-old children, residing in the central region of Limpopo Province, South Africa

The present study evaluated levels of growth factors and their associations with nutritional status with emphasis on stunting in children at 1 and 3 years of age. A follow-up study on a birth cohort (n 219) of children from villages in the central region of the Limpopo Province was undertaken. Of the original cohort, 156 and 162 could be traced and assessed at ages 1 and 3 years, respectively. Data collected included socio-demographic characteristics, anthropometric measurements, dietary intake and fasting blood (collected from 116 and 145 children at 1 and 3 years, respectively) for growth factor analysis (insulin-like growth factor (IGF)-1, IGF binding protein (BP)-1, IGFBP-3, leptin, glucose and insulin). At 1 year it was found that stunted children had lower leptin levels while their IGFBP-1 levels were higher than that in normal children. These differences were, however, not observed at 3 years. Furthermore at 1 year the biochemical parameters were more related to length measures whereas at 3 years the parameters were more associated with weight measures. The observed stunting in this group of children may be a result of chronic undernutrition resulting in long-term growth faltering which is already evident at 1 year. Thus the observed phenomenon might be an adaptive mechanism adopted by children's metabolic processes as they grow up in an environment with inadequate essential nutrients due to poor weaning practices and consumption of a diet of poor quality, resulting in them gaining more weight at the expense of linear growth.

Prevalence and determinants of stunting and overweight in 3-year-old black South African children residing in the Central Region of Limpopo Province, South Africa

Objectives

To determine the prevalence of stunting, wasting and overweight and their determinants in 3-year-old children in the Central Region of Limpopo Province, South Africa.

Design

Prospective cohort study.

Setting

Rural villages in the Central Region of the Limpopo Province, South Africa.

Subjects

One hundred and sixty-two children who were followed from birth were included in the study. Anthropometric measurements and sociodemographic characteristics of the children were recorded.

Results

Height-for-age Z-scores were low, with a high prevalence of stunting (48%). The children also exhibited a high prevalence of overweight (22%) and obesity (24%). Thirty-one (19%) children were both stuntedandoverweight. Gaining more weight within the first year of life increased the risk of being overweight at 3 years by 2.39 times (95% confidence interval (CI) 1.96–4.18) while having a greater length at 1 year was protective against stunting (odds ratio (OR) 0.41; 95% CI 0.17–0.97). Having a mother as a student increased the risk for stunting at 3 years by 18.21 times (95% CI 9.46–34.74) while having a working mother increased the risk for overweight by 17.87 times (95% CI 8.24–38.78). All these factors also appeared as risks or as being protective in children who were both overweight and stunted, as did living in a household having nine or more persons (OR 5.72; 95% CI 2.7–12.10).

Conclusion

The results of this study highlight the importance of evaluating anthropometric status in terms of both stunting and overweight. Furthermore, it is important to realise the importance of normal length and weight being attained at 1 year of age, since these in turn predict nutritional status at 3 years of age.