Tracking of infant and young child feeding practices among 9- to 24-month-old children in Nepal: the MAL-ED Birth Cohort Study

Methodological Aspects of Diet Quality Indicators in Childhood: A Mapping Review

Diet quality indicators (DQIns) are tools that aim to assess an individual's overall diet quality. Previous reviews focused mainly on health-related outcomes but did not provide detailed information about components, assessment variables, or important methodological issues for the development and application of DQIns in the pediatric age. The current mapping review aims to provide comprehensive guidance regarding DQIns developed through a priori methodology in children aged ≤14 y that have been applied worldwide. A mapping review was conducted, whereby 1665 original articles describing the development, modifications, and updates of DQIns, published up to June 26, 2020, in English and Spanish, were retrieved. A total of 139 articles were identified and classified into 13 subgroups. There were 10 overall DQIns: Healthy Eating Indexes (n = 25), Dietary Diversity Scores (n = 20), Diet Quality Indexes (n = 16), Food Variety Scores (n = 11), Healthy and Unhealthy Scores (n = 11), Feeding and Eating Indexes (n = 10), Diet Quality Scores (n = 5), Nutritional Adequacy and Micronutrients Indexes (n = 5), Dietary Guidelines Indexes (n = 5), and Other Healthy Diet Indexes (n = 13). Three additional subgroups of dietary and lifestyle indicators found were Mediterranean Diet Indexes (n = 10), Diet-Lifestyle Indexes (n = 5), and Breakfast Quality Indexes (n = 3). This compilation of DQIns will help researchers select the most appropriate tool for future epidemiological studies by considering a careful selection of information about the assessment components, scoring methods, and key methodological issues. The main limitations of this review are that, due to its nature, a risk-of-bias assessment was not performed and the article screening was completed in 2 databases (PubMed/MEDLINE and Scopus). More research is needed to identify health-related outcomes associated with DQIns in the pediatric population, using clearer and more standardized methodological criteria.

Feeding Practices and Undernutrition in 6⁻23-Month-Old Children of Orthodox Christian Mothers in Rural Tigray, Ethiopia: Longitudinal Study

Fasting period and fasting status affect the feeding practices and nutritional status of Ethiopian Orthodox mothers. Even if children are exempted from fasting, some mothers do not prepare their food from animal sources as it could contaminate utensils for cooking family foods. Therefore, the objective of this study was to assess feeding practices and undernutrition in 6⁻23-months old children whose mothers are Ethiopian Orthodox religion followers during lent fasting and non-fasting periods in rural Tigray, Northern Ethiopia, and to identify associated factors. A community-based longitudinal study was carried out in Ethiopian Orthodox lent fasting and non-fasting periods. Using a multi-stage systematic random sampling technique, 567 and 522 children aged 6⁻23 months old participated in the fasting and non-fasting assessments, respectively. Statistical analyses were done using logistic regression, an independent sample t-test, Wilcoxon signed-rank (WSRT) and McNemar's tests. The prevalences of stunting, underweight and wasting were 31.6⁻33.7%, 11.7⁻15.7% and 4.4⁻4.8%, respectively. The weight-for-height (WHZ) and height-for-age (HAZ) values for children of fasting mothers were significantly lower (p < 0.05) compared to those of non-fasting mothers. Likewise, the median weight-for-age (WAZ) and diet diversity score (DDS) of children of fasting mothers were also significantly higher in non-fasting than in fasting periods. A small proportion of children (2.3⁻6.7%) met the minimum acceptable diet (MAD) in the study population, but these measures were significantly increased (p < 0.001) in the children of non-fasting mothers. Mother's fasting during lactation period of the indexed child was amongst the independent factors common in child stunting, underweight and wasting. Nutritional status and feeding practices of 6⁻23-month-old children are affected by maternal fasting during the fasting period. Therefore, without involvement of religious institutions in the existing nutritional activities, reduction of undernutrition would not be successful and sustainable.

Cobalamin and Folate Status among Breastfed Infants in Bhaktapur, Nepal

Cobalamin and folate are crucial micronutrients during infancy and they are required for growth and cognitive development. Due to the monotonous and predominantly vegetarian-based complementary feeding and poor maternal micronutrient status, infants from low- and middle-income countries are susceptible to cobalamin deficiency. However, data on plasma cobalamin and folate and the functional markers methylmalonic acid and total homocysteine from breastfed infants in Nepal are still needed. We collected plasma samples from 316 6–11-month-old breastfed infants with a length-for-age of less than minus one z-score and analyzed blood for plasma folate, cobalamin, methylmalonic acid and total homocysteine concentrations. Cobalamin deficiency (plasma cobalamin <148 pmol/L) was found among 11%, whereas 24% of the infants had plasma cobalamin concentrations between 148–221 pmol/L. Elevated total homocysteine (>10 µmol/L) and methylmalonic acid (>0.28 µmol/L) indicating functional cobalamin deficiency were found among 53% and 75% of the infants, respectively. Based on a combined indicator of cobalamin status, 58% were found to have low cobalamin status. However, folate deficiency (<10 nmol/L) was not found as the lowest value of plasma folate was 20.7 nmol/L. It is important to examine the extent to which poor cobalamin status during infancy has immediate or long-term consequences.

Severely inadequate micronutrient intake among children 9-24 months in Nepal-The MAL-ED birth cohort study

Prevalence of micronutrient deficiencies is high among infants and children in low- and middle income countries, but knowledge about nutrient adequacy across the complementary feeding period is limited. We investigated probability of adequacy (PA) of breast milk and complementary food combined and nutrient density adequacy (NDA) of complementary food and tracking of NDA over time among 229 children from 9-24 months of age in Bhaktapur, Nepal. Monthly, 24 h dietary recalls (16 in total) were performed and subgrouped into four 4-month time periods. Ten micronutrients (thiamin, riboflavin, niacin, vitamin B6 , folate, vitamin C, vitamin A, calcium, iron, and zinc) were assessed. Nutrient density was defined as the amount of a nutrient in a child's complementary food per 100 kcal, whereas NDA was the nutrient density as percentage of the context specific desired nutrient density. Tracking of NDA was investigated using generalized estimating equations models. PA for B vitamins (except riboflavin), vitamin A, calcium, iron, and zinc (low absorption group) was very low (0% to 8%) at all time slots. Median (IQR) mean PA (of all 10 micronutrients) increased from 11% (9, 15) in the second to 21% (10, 35) in the last time slot. Median value for mean nutrient density adequacy of all micronutrients varied between 42% and 52%. Finally, tracking of NDA was low (correlation <0.30) or moderate (0.30-0.60) indicating poor association between the first and subsequent measurements of NDA. These findings raise grave concerns about micronutrient adequacy among young children in Nepal. Urgent interventions are needed.