A review of complementary feeding practices in South Africa

Dietary intake and growth of HIV exposed and unexposed 6-12 months old infants in South Africa

Factors affecting the growth of HIV-exposed-uninfected (HEU) children are multi-factorial, with limited information available on the dietary intake from 6 months. This study compared the dietary intake, micronutrient composition of breastmilk, and growth of HEU and HIV-unexposed-uninfected (HUU) infants aged 6 and 12 months in an urban setting. A repeated cross-sectional study used structured questionnaires to collect socio-demographic, dietary intake, food group data, and anthropometric measurements in the Siyakhula study. The HEU (48%) and HUU (52%) infants were included (total n = 181). At 6 months, HEU infants had lower weight-for-age z-scores (WAZ) (-0.6 ± 1.1 vs. 0.1 ± 1.2; p < 0.001), length-for-age z-scores (-0.8 ± 1.4 vs. -0.1 ± 1.2; p < 0.001), and mid-upper-arm circumference-for-age z-scores (MUACAZ) (0.5 ± 1.1 vs. 1.0 ± 0.9; p < 0.001) than HUU infants. At 12 months, HEU infants had lower WAZ, MUACAZ, and weight-for-length z-scores compared to HUU infants (p < 0.05). Stunting was found at 6 (15%) and 12 (12%) months in HEU infants. The micronutrient composition of breastmilk fed to both groups was similar. Breastfeeding rates were lower in HEU than in HUU infants at 6 (49% vs. 64%; p = 0.005) and 12 (24% vs. 46%; p = 0.002) months. Less than 3% of HEU and HUU infants achieved minimal dietary diversity scores at 12 months. Dietary intake of fat was similar in all breastfed infants, but iron and vitamin B12 were higher in non-breastfed HEU infants at 12 months. HEU infants had lower breastfeeding rates than HUU infants. A lack of dietary diversity was found in all infants. Nutrition education and counselling in the complementary feeding phase are essential for optimal growth.

Feeding practices of caregivers with children attending early childhood development centres in Xhariep, South Africa

Background

In low- to middle-income countries, malnutrition is a major contributing factor in children failing to achieve their developmental potential. The prevention of malnutrition requires, among others, nutritious, diverse and safe foods in early childhood.

Aim

The study aimed to determine primary caregivers' choices and motivation for the foods they fed their children.

Setting

The study was conducted among early childhood development centres in the Xhariep District, Free State.

Methods

A qualitative study was undertaken. Twelve participants who met the inclusion criteria were conveniently sampled. Semi-structured interviews were conducted to find out the primary caregivers' choices and motivation for foods they fed their children until data saturation was reached.

Results

The mean age of the participants was 31 years. Nine of the participants relied on social grants as a source of income. The participants reported feeding their children mainly maize porridge, milk, juice, and water. Vegetables and meat were fed to the children once a week. Fruits were fed to the children at the beginning of the month.

Conclusion

The level of education, employment status, and community support influenced the primary caregivers' feeding practices. The content of the diets of their children was insufficient in vegetables and fruit, not only placing the children at risk of undernutrition but also at risk of obesity and micronutrient deficiencies. Primary caregivers ensured their children were fed, although limited foods were offered.

Contribution

This research creates awareness of the level of social progress and access to resources within rural communities in the Xhariep district, and gives the opportunity to extend this research to confirm these findings in other poverty-stricken areas.

Potential of Egg as Complementary Food to Improve Nutrient Intake and Dietary Diversity

The original aim was to determine the effect of egg consumption on infant growth in a low socioeconomic community in South Africa in a randomized controlled trial. Enrolment was, however, prematurely stopped due to COVID-19 lockdown regulations. The resultant small sample (egg group n = 70; control group n = 85) was followed up to assess the feasibility of egg consumption for eight months in terms of dietary intake, egg usage and perceived effects of lockdown on child feeding. Egg consumption remained low in the control group, <10% consumed egg ≥4 days/week at the follow-up points. In the egg group, egg was frequently consumed at midpoint (daily 87.1%, 4−6 days 8.1%) and endpoint (daily 53.1%, 4−6 days 21.9%). At endpoint, dietary intake of cholesterol and vitamin D was higher, and intake of niacin and vitamin B6 lower in the egg group compared to the control group. Dietary diversity was low, 36.2% of the egg group and 18.9% of the control group (p < 0.05) achieved minimum dietary diversity at endpoint. No babies developed egg allergy or sensitization, and adjusted regression analysis showed that frequency of egg intake was not related with the incidence or duration of allergy-related symptoms. This study showed that frequent egg consumption can contribute safely to complementary food for babies, especially in low- and middle-income countries.

Retail Cost and Energy Adjusted Cost Are Associated with Dietary Diversity and Nutrient Adequacy for Diets of 6–24 Months Children

Poor nutrition during the first two years of life has long term consequences, but resource-poor households often do not have the means to access nutrient-dense and diverse diets. Pooled data of 24-h dietary recalls (n = 3336) and 2019 retail food prices were analyzed to determine associations of retail cost and energy cost (per 100 kcal) with diet quality indicators for diets of 6–24-month-old South African children who were breastfed (BF-diet) and not breastfed (NBF-diet) during the 24-h recall period. Compared to the BF-diet, retail cost for the NBF-diet was three times higher for age 6–11 months, and double for age 12–17 months. Higher retail cost and energy cost were both associated with higher mean adequacy ratios and dietary diversity scores for BF and NBF diets, except energy cost for the NBF-diet for age 6–11 months. Overall, inclusion of flesh foods, vitamin A-rich fruits and vegetables, and other fruit and vegetables increased from the lowest to the highest retail cost tertile. The higher cost of more nutritious diets highlights the importance of the affordability of diets in interventions aimed at improving diet quality. Possible strategies include: identifying the most-affordable foods within each food group, focusing on foods that provide multiple key micronutrients, and the inclusion of locally available indigenous foods.

Lockdown-Associated Hunger May Be Affecting Breastfeeding: Findings from a Large SMS Survey in South Africa

The impact that the COVID-19 pandemic has had, and will continue to have, on food security and child health is especially concerning. A rapid, Short Message Service (SMS) Maternal and Child Health survey was conducted in South Africa in June 2020 (n = 3140), with a follow-up in July 2020 (n = 2287). This was a national cross-sectional survey conducted among pregnant women and mothers registered with the MomConnect mhealth platform. Logistic regression was conducted to explore the associations between breastfeeding, maternal depressive symptoms, and hunger in the household. High breastfeeding initiation rates and the early introduction of other foods or mixed milk feeding were found. The prevalence of depressive symptoms in this survey sample was 26.95%, but there was no association between breastfeeding behaviour and depressive symptom scores (OR = 0.89; 95% CI: 0.63, 1.27). A positive correlation was found between not breastfeeding and not going to the health clinic. The odds of hungry mothers breastfeeding were significantly lower (OR = 0.66; p = 0.045). This result also holds in a multivariate framework, including covariates such as depressive symptoms, attendance of a PHC facility, and whether the infant was older than 3 months. Support for breastfeeding must include support, such as economic support, for breastfeeding mothers, to enable them to access nutritious diets. Mothers also need reassurance on the quality of their breastmilk and their ability to breastfeed and should be encouraged to continue to attend the health clinic regularly.

Persistent Malnutrition and Associated Factors among Children under Five Years Attending Primary Health Care Facilities in Limpopo Province, South Africa

Despite years of interventions intended to reduce child malnutrition in South Africa, its negative effects, stunting in particular, persist mainly among children under five years old living in under-resourced regions. A cross-sectional study was conducted to determine the prevalence of malnutrition and associated factors among 404 children under age five attending childcare services with their mothers in selected healthcare facilities of Limpopo Province, South Africa. Anthropometry, socio-demographics and obstetric history were collected. Height-for-age, weight-for-age and body mass index-for-age Z-scores were used to determine stunting, underweight and thinness among children, respectively. Logistic regression analyses were performed to generate the factors associated with malnutrition. Stunting (45.3%) was the prevalent form of malnutrition among children under age five, affecting boys (51.7%) more than girls (38.8%) and children aged 12–23 months (62.4%) more than those <11 months old (40.1%), in addition to the overall prevalence of underweight (29.0%) and thinness (12.6%). Boys had increased odds of stunting (adjusted odds ratio, AOR = 2.07, 95% CI: 1.26–3.41, p = 0.004) and underweight (AOR = 2.17, 95% CI: 1.32–3.57, p = 0.002) than girls. Children aged 12–23 months were more likely to be stunted (AOR = 4.79, 95% CI: 2.36–9.75, p ≤ 0.0001) than children aged ≤11 months. Delayed introduction of solid foods increased the odds of stunting (AOR = 5.77, 95% CI: 2.63–12.64, p ≤ 0.0001) and underweight (AOR = 2.05, 95% CI: 1.08–3.89, p = 0.028). Children with normal birth weight were less likely to be thin (AOR = 0.42, 95% CI: 0.19–0.92, p = 0.029) and underweight (AOR = 0.34, 95% CI: 0.17–0.68, p = 0.003) than children who had low birth weight. Children whose mothers had obtained secondary school education (AOR = 0.39, 95% CI: 0.16–0.97, p = 0.044), and Grade 12 or post-Grade 12 education (AOR = 0.32, 95% CI: 0.12–0.83, p = 0.020) were less likely to be stunted than were children of mothers who had only primary school education. Suboptimal complementary feeding predisposed children to stunting and underweight. National nutrition programs should be context-specific to improve the introduction of complementary foods among children, especially in the remote and poor areas.

Perceptions of grandmothers and HIV-infected mothers on infant feeding practices in a rural South African district

Background

Despite enormous interventions aimed at preventing mother-to-child transmission (MTCT) of HIV, cultural practices on mixed infant feeding remain prevalent. Complementary food provision to infants seems to be the most common and acceptable form of infant feeding highly endorsed by grandmothers.

Aim

This study aimed to explore the perceptions of grandmothers and HIV-infected mothers on infant feeding practices in the context of prevention of mother-to-child transmission.

Setting

This study was undertaken in two primary healthcare facilities in the Mpumalanga province, South Africa.

Methods

A qualitative exploratory narrative design was used to conduct four focus group discussions with 32 purposefully selected grandmothers and 21 in-depth interviews with postnatal HIV-infected women in the two identified health facilities. Data were analysed using an interthematic inductive analysis approach, resulting in major themes and subthemes supported by participants’ excerpts.

Results

Four themes emerged showing (1) high mixed feeding endorsement because of the need to adhere to conventional practices, strengthen the umbilicus and have fuller, fat and calmer babies; (2) infant feeding fallacies and stigma reflected by exclusive breastfeeding period confusion, breastfeeding scepticism and infant feeding stigma; (3) breastfeeding endorsement for other disease prevention and family support for breastfeeding and (4) conflict between traditional and western infant feeding approaches.

Conclusion

Total elimination of MTCT of HIV in a rural context calls for targeted education for grandmothers addressing their perceptions and practices of infant feeding. The knowledge of the identified factors encouraging mixed infant feeding can assist in designing programmes to change community beliefs on infant feeding. Cultural, social and psychosocial factors should be addressed when making recommendations for exclusive breastfeeding for HIV-positive mothers.

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.