Feeding practices for infants and young children during and after common illness. Evidence from South Asia.

Global evidence shows that children's growth deteriorates rapidly during/after illness if foods and feeding practices do not meet the additional nutrient requirements associated with illness/convalescence. To inform policies and programmes, we conducted a review of the literature published from 1990 to 2014 to document how children 0-23 months old are fed during/after common childhood illnesses. The review indicates that infant and young child feeding (IYCF) during common childhood illnesses is far from optimal. When sick, most children continue to be breastfed, but few are breastfed more frequently, as recommended. Restriction/withdrawal of complementary foods during illness is frequent because of children's anorexia (perceived/real), poor awareness of caregivers' about the feeding needs of sick children, traditional beliefs/behaviours and/or suboptimal counselling and support by health workers. As a result, many children are fed lower quantities of complementary foods and/or are fed less frequently when they are sick. Mothers/caregivers often turn to family/community elders and traditional/non-qualified practitioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours guide the use of 'special' feeding practices, foods and diets for sick children. A significant proportion of mothers/caregivers turn to the primary health care system for support but receive little or no advice. Building the knowledge, skills and capacity of community health workers and primary health care practitioners to provide mothers/caregivers with accurate and timely information, counselling and support on IYCF during and after common childhood illnesses, combined with large-scale communication programmes to address traditional beliefs and norms that may be harmful, is an urgent priority to reduce the high burden of child stunting in South Asia.

Introduction

About a quarter (26%) of the world's children under five live in South Asia. Thirty‐eight per cent of them have stunted growth (UNICEF 2015). Stunting, or linear growth retardation during early childhood, is an outcome of biological and/or psychosocial deprivation (Stewart et al. 2013). The short‐term and long‐term consequences of stunting include impaired survival, physical growth and cognitive development in pre‐school age children; poor school readiness, school enrolment and learning outcomes in school‐age children; increased risk of obstetric complications and mortality in women; and reduced height, productivity and earnings in adults (Grantham‐McGregor et al. 2007; Walker et al. 2007; de Onis et al. 2013).

A significant proportion of stunting can happen prenatally. However, evidence indicates that most stunting in low‐income and middle‐income countries occurs during the first 24 months of life as a result of suboptimal breastfeeding and complementary feeding practices, often in combination with recurrent infections (Stewart et al. 2013; Jones et al. 2014). Furthermore, children's nutritional status can deteriorate rapidly during/after illness if the additional nutrient requirements associated with illness/convalescence are not met and nutrients are diverted from growth and development towards the immune response. Children's poor appetite induced by illness can contribute to perpetuate the vicious cycle of infection and stunting (Brown 2003; Ramachandran & Gopalan 2009; Gulati 2010; Neumann et al. 2012; Richard et al. 2014). Additionally, in low‐income and middle‐income countries, infant and young child feeding (IYCF) practices during and after common childhood illnesses can be particularly poor owing to harmful traditional practices and the low coverage/quality of primary health care services (Bhutta & Salam 2012; de Onis et al. 2012; Stewart et al. 2013).

Recognizing the importance of optimal IYCF practices for child survival, growth and development, the World Health Organization (WHO) launched in 2003 the Global Strategy for Infant and Young Child Feeding and issued in 2003 the Guiding Principles for Complementary Feeding of Breastfed and Non‐Breastfed Children (WHO/UNICEF 2003; WHO 2003a,2003b). These global frameworks highlight the importance of optimal IYCF practices during and after common childhood illnesses such as diarrhoea and pneumonia and emphasize the need to increase fluid intake during illness while feeding is maintained and increase food intake during convalescence. In addition, appropriate IYCF during and after illness is part of the WHO‐led Global Strategy for the Integrated Management of Childhood Illnesses (WHO 2005). The definition and measurement of the indicators for assessing IYCF practices – beyond the scope of this paper – are comprehensively detailed elsewhere (WHO 2008, 2010).

In South Asia, breastfeeding is a quasi‐universal practice. An estimated 96% of children are breastfed at some point in their lives, and most (80%) continue to be breastfed at 2 years of age (Dibley et al. 2010; UNICEF 2015). However, data from household surveys across the region indicate that the majority of South Asian children are not fed as per the internationally agreed upon recommendations: only a quarter (27%) of newborns start breastfeeding within 1 h of birth; less than half (48%) of infants 0–5 months old are exclusively breastfed; only about half (56%) of infants 6–8 month olds are fed soft, semi‐solid or solid foods; and a mere 21% of children 6–23 months old are fed a diet that meets the minimum requirements in terms of feeding frequency and diet diversity (Senarath et al. 2012; UNICEF 2015). In view of this situation, researchers and practitioners have not hesitated to refer to IYCF in South Asia as a crisis (Memon 2012). There is evidence that the incidence and severity of common childhood diseases are high in this region (Walker et al. 2013). However, less is known about IYCF practices during and after common childhood illnesses in South Asia.

For the purpose of this paper, South Asia refers to the eight member countries of the South Asia Association for Regional Cooperation, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka.

Thus, the objective of this paper is threefold: (1) document the current IYCF practices during and after common childhood illnesses – particularly diarrhoea, fever and pneumonia – and their trends since 1990 in South Asia; (2) document caregiver's behaviours and health providers' practices with respect to IYCF during and after common childhood illnesses in South Asia; and in light of the preceding objectives, (3) identify priorities in terms of policy formulation, programme design, research and advocacy to protect, promote and support optimal IYCF practices during and after common childhood illnesses in South Asia post 2015.

Information on infant and young child feeding (IYCF) behaviors and practices during common childhood illnesses in South Asia is limited. Information of IYCF after illnesses is virtually inexistent. The evidence available indicates that IYCF practices during common childhood illnesses are far from optimal.

When sick, most children (up to 98%) continue to be breastfed although a significant proportion (up to 49%) are breastfed less frequently than usual. Few sick children (<20%) are breastfed more frequently than usual, as is recommended, to compensate for the additional fluid and nutrient requirements associated with illnesses.

When sick, many children (up to 75%) see their complementary foods restricted in frequency, quantity and/or quality due to children's anorexia (perceived or real), lack of awareness of caregivers' about the feeding needs of sick children, traditional beliefs, or sub‐optimal counselling and support by health workers.

In general, health providers do not advise mothers to increase breastfeeding frequency while encouraging sick children to eat soft, varied, and favourite foods during illness, as is recommended. Important policy, programme and capacity gaps exist with respect to IYCF for children during and after common childhood illnesses in many South Asian countries.

Methods

We reviewed data and information from two primary sources: Demographic Health Surveys (DHS) and peer‐reviewed publications. DHS collects information on care‐seeking and care‐giving practices during diarrhoea, fever and pneumonia using standardized sampling methodologies, interview tools and data analyses procedures, with minor country‐specific adaptations. We reviewed the national DHS surveys conducted in South Asia between 1990 and 2014 to document the prevalence of common childhood illnesses – diarrhoea, fever and pneumonia – in children 0–23 months old, the frequency and type of medical advice that caregivers sought, the type of treatment and/or advice that children received and how children were fed during common childhood illnesses. For countries with two data points, trends in IYCF practices during and after common childhood illness were estimated as well as the average annual rate of improvement to quantify the average improvement in a given indicator per year between the base year and end year.

We also conducted a comprehensive review of the peer‐reviewed literature published between January 1990 and December 2014. Peer‐reviewed articles were identified through an online PubMed search using the following search terms and search filters: (1) search terms: , , , <pneumonia>, <diarrhea/diarrhoea> and , each term combined with , , , , , , , <Sri Lanka> and/or ; (2) search filters: age <child 0–59 months>; language: ; text availability: ; species :<human>; and search fields: