Eating and feeding behaviours in children in low-income areas in Nairobi, Kenya

Prevalence and overlap of known undernutrition risk factors in children in Nairobi Kenya

We aimed to describe the co‐occurrence of known risk factors for undernutrition and the prevalence of modifiable risks in wasted, stunted and healthy children. Quota sampling was used to recruit healthy [weight for age Z scores (WAZ) > −2 SD] and undernourished [weight for length (WLZ) or WAZ scores ≤ −2 SD] children aged 6–24 months from seven clinics in low‐income areas of Nairobi. Structured interviews were used to identify exposure to socioeconomic, water and hygiene, infant feeding, dietary and behavioural risks (low interest in food, high food refusal and force feeding). We recruited 92 wasted WLZ ≤ −2 SD, 133 stunted (length for age Z scores LAZ ≤ −2 SD) and 172 healthy (LAZ and WLZ > 2SD) children. Nearly all children were exposed to hygiene risks (90%) and low dietary diversity (95%) regardless of nutritional status. Stunted children were more likely to be exposed to socio‐economic risks (54% healthy, 64% wasted and 72% stunted; P = 0.001). Compared with healthy children, wasted and stunted children were more likely to be exposed to infant feeding (25% healthy, 40% wasted and 41% stunted; P = 0.02) and behaviour risks (24% healthy, 49% wasted, and 44% stunted; P = 0.004). Overall, wasted and stunted children were twice as likely to be exposed to more than three risks (23% healthy, 48% wasted, and 50% stunted; P = <0.001). They were also more likely to be exposed to more than three modifiable risks (dietary, handwashing and behaviour risks). Wasting and stunting are associated with exposure to multiple risk factors, many of which are potentially modifiable using targeted advice.

Development of a Scale to Measure Infant Eating Behaviour Worldwide

In order to create a short, internationally valid scale to assess eating behaviour (EB) in young children at risk of undernutrition, we refined 15 phrases describing avidity or food refusal (avoidance). In study one, 149 parents matched phrases in English, Urdu, Cantonese, Indonesian or Greek to videos showing avidity and avoidance; 82-100% showed perfect agreement for the avidity phrases and 73-91% for the avoidant phrases. In study two, 575 parents in the UK, Cyprus and Indonesia (healthy) and in Kenya, Pakistan and Guatemala (healthy and undernourished) rated their 6-24 months old children using the same phrases. Internal consistency (Cronbach's α) was high for avidity (0.88) and moderate for avoidance (0.72). The best-performing 11 items were entered into a principal components analysis and the two scales loaded separately onto 2 factors with Eigen values > 1. The avidity score was positively associated with weight (r = 0.15 p = 0.001) and body mass index (BMI) Z scores (r = 0.16 p = 0.001). Both high and low avoidance were associated with lower weight and BMI Z scores. These scales are internationally valid, relate to nutritional status and can be used to inform causes and treatments of undernutrition worldwide.

Eating and feeding behaviours in children in low-income areas in Nairobi, Kenya

Child eating and caregiver feeding behaviours are critical determinants of food intake, but they are poorly characterized in undernourished children. We aimed to describe how appetite, food refusal and force‐feeding vary between undernourished and healthy children aged 6–24 months in Nairobi and identify potential variables for use in a child eating behaviour scale for international use. This cross‐sectional study was conducted in seven clinics in low‐income areas of Nairobi. Healthy and undernourished children were quota sampled to recruit equal numbers of undernourished children (weight for age [WAZ] or weight for length [WLZ] Z scores ≤2SD) and healthy children (WAZ > 2SD). Using a structured interview schedule, questions reflecting child appetite, food refusal and caregiver feeding behaviours were rated using a 5‐point scale. Food refusal and force‐feeding variables were then combined to form scores and categorized into low, medium and high. In total, 407 child–caregiver pairs, aged median [interquartile range] 9.98 months [8.7 to 14.1], were recruited of whom 55% were undernourished. Undernourished children were less likely to ‘love food’ (undernourished 78%; healthy 90% p = < 0.001) and more likely to have high food refusal (18% vs. 3.3% p = <0.001), while their caregivers were more likely to use high force‐feeding (28% vs. 16% p = 0.03). Undernourished children in low‐income areas in Nairobi are harder to feed than healthy children, and force‐feeding is used widely. A range of discriminating variables could be used to measure child eating behaviour and assess the impact of interventions.