Infant and young child feeding practices and its associated factors among mothers of under two years children in a western hilly region of Nepal.

Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. Nepal government has developed and implemented different programs to improve infant and young child feeding practice. However, the practice remains poor and is a major cause of malnutrition in Nepal. This study aims to identify infant and young child feeding practices and its associated factors among mothers of children aged less than two years in western hilly region of Nepal. A descriptive cross-sectional study was carried out among 360 mothers of under two years' children in Syangja district. A semi structural questionnaire was used. Data was entered in EpiData and analyzed using IBM SPSS version 21. Descriptive statistics were used to report the feeding practices and other independent variables. Bivariate and multivariate logistic regression model was used to establish the factors associated with infant and young child feeding practices. The prevalence of breastfeeding, timely initiation of breastfeeding, exclusive breastfeeding, timely initiation of complementary feeding, minimum dietary diversity, minimum meal frequency and minimum acceptable diet (MAD) were 95.6%, 69.2%, 47.6%, 53.3%, 61.5%, 67.3% and 49.9% respectively. Normal delivery (AOR 6.1, 95% CI 1.2-31.3) and higher maternal autonomy (AOR 5.2, 95% CI 1.8-14.6) were significantly associated with exclusive breastfeeding. Similarly, crop production and food security (AOR 3.8, 95% CI 1.9-7.7), maternal knowledge on MAD (AOR 2.5, 95% CI 1.0-6.2) and maternal autonomy (AOR 4.2, 95% CI 2.1-8.4) were significantly associated with minimum acceptable diet. Factors such as maternal education, maternal health services utilization, maternal knowledge, and maternal autonomy were associated with infant and young child feeding practices, which warrants further attention to these factors to reduce malnutrition.

Introduction

Infant and young child feeding (IYCF) is a key area to improve child survival and promote healthy growth and development [1]. The first two years of the child’s life provide a critical window of opportunity to ensure survival, growth, and development through optimum infant and young child feeding practices [2]. Appropriate infant and young child feeding practices help to prevent almost 19% of all under-five deaths [3]. World Health Organization has recommended the initiation of breastfeeding within one hour of birth, exclusive breastfeeding for the first six months, and introduction of nutritionally adequate and safe complementary food at 6 months together with continuing breastfeeding up to two years of age or beyond [4].

Globally only about 44% of infants less than six months old were exclusively breastfed and 45% of the global child deaths are associated with under-nutrition. More than two-thirds of malnutrition-related child deaths are associated with inappropriate feeding practices during the first two years of life [5]. Improvement in infant and young child feeding practices is likely to reduce the burden of diarrhea-related morbidity and mortality [6].

The Nepal Demographic and Health Survey (NDHS) in 2016 reported about 66% of 0–5 months children were exclusively breastfeed in Nepal. Similarly, the prevalence of minimum meal frequency, minimum dietary diversity, and minimum acceptable diet was 71%, 47%, and 36% respectively. Breastfeeding and complementary feeding practices vary dramatically across different province of Nepal. More than fifty percent of children received a minimum acceptable diet in Gandaki province of Nepal, while this figure is only eighteen percentage in Province two of Nepal [7].

Many studies have been conducted to identify factors associated with infant feeding practices in Nepal. Evidence suggests that education, household wealth status, geographical location, maternal age, antenatal visit, post-natal visit, household food security, family community support are associated with exclusive breastfeeding and complementary feeding in Nepal [8-10]. Maternal factors such as decision-making capacity, education, knowledge, and maternal health services utilization are important factors for child feeding practices [10-13]. These factors pose better access and control over household resources to mothers which allows them to allocate resources to maintain and improve feeding practices [14].

The Government of Nepal has developed and implemented different acts, policies, strategies, and programs to improve infant feeding practices [15]. IYCF is a priority strategy of the Ministry of Health and Population. Despite the scale-up of this program was scaled up to all districts of Nepal, IYCF practices remain poor [16]. Therefore, it is more important to understand local and regional child feeding practices and their associated factors before developing strategies aimed to improve child feeding practices in Nepal. So, this study helps to determine factors associated with child feeding practices in the hilly region of Nepal and to generate local evidence for informed planning of the interventions to address poor IYCF practices.

Materials and methods

Study design and population

This was a community-based cross-sectional study conducted during September 2019 to August 2020 in Syangja district Nepal. Syangja is a part of Gandaki Province and is one of the 77 districts of Nepal. It covers an area of 1,164 km2 (449 square miles). As per census 2011, The district has a population of 289,148 [17]. It is located 215 kilometers west of the capital city of Nepal. There are 20 hilly districts in Nepal where 45 percent of the total Nepalese population resides. Altogether there are five urban municipalities and six rural municipalities in Syangja district. The study area was two urban municipalities (Bhirkot and Chapakot) and two rural municipalities (Phedikhola and Biruwa) of Syangja district. A ward is the smallest administrative unit in Nepal and the number of wards in a municipality ranges from a minimum of five to a maximum of 33. The study population was mothers and their children aged 0–23 months. Total population of child aged 0–23 months in Syangja district is 24,123 [17]. Considering the prevalence of minimum acceptable diet as 36%; at a 5% margin of error and 5% level of significance the final sample size was 360. The response rate in this study was 100%.

Multistage random sampling technique was used to select the participants. In the first stage, two rural municipalities and two urban municipalities were chosen randomly from the total list of municipalities. In the second stage, two wards from each municipality were selected by simple random sampling. In the final stage, participants were selected proportionate to population size from selected wards by using the list of under two-year children as a sampling unit. The list of the children aged 0–23 months was obtained from a comprehensive list maintained by female community health volunteers and immunization register maintained by health post.

Data collection tools and variables

Tools

Face to face interview was conducted with 360 mothers having children less than 2 years in Syangja district. NA and five trained enumerators were involved in data collection from 5 January 2020 to 26 January 2020. The average time for an interview was 45 minutes.

A structured questionnaire was prepared. The study tool was adopted from Nepal Demographic Health Survey (NDHS) 2016 with necessary modification. The questionnaire was divided into six sections: socio-demographic and socio-economic information, maternal health services related information, infant and young child feeding practices related information, maternal knowledge about IYCF, information on agriculture-related practices, and information on maternal autonomy. The questionnaire included 69 questions.

Outcome variables

To assess child feeding practices, we used six core indicators of IYCF practices. These indicators were recorded using information about foods given to the child in the last 24 hours before the interview according to the definition of IYCF core indicators guidelines. According to WHO, IYCF indicators were defined as follows.

Early initiation of breastfeeding was defined as the proportion of children aged 0–23 months who commenced breastfeeding within the first hour of birth.

Exclusive breastfeeding was defined as the proportion of infants 0–5 months of age who were fed no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse), but allows the infant to receive oral rehydration salt, drops, and syrups (vitamins, minerals, and medicines).

Introduction of complementary foods (solid, semi-solid, or soft foods) was defined as the proportion of infants who initiated solid, semi-solid, or soft foods in the six months of age.

Minimum dietary diversity was defined as the proportion of children aged 6–23 months who received foods from four or more out of seven food groups. The seven food groups are grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry, and liver/organ meats); eggs; vitamin A‐rich fruits and vegetables; other fruits and vegetables.

Minimum meal frequency was defined as the proportion of breastfed and non-breastfed children 6–23 months of age who received solid, semi-solid, or soft food (including milk feed for non-breastfeed children) minimum number of times or more. The minimum number of times was defined as two times for breastfed infants 6–8 months; three times for breastfed children 9–23 months; four times for non‐breastfed children 6–23 months.

Minimum acceptable diet (MAD) was defined as the proportion of children 6–23 months of age who received a minimum acceptable diet (apart from breast milk). MAD is the sum of two fractions: (1) the proportion of breastfed children 6–23 months of age who had at least the minimum dietary diversity and the minimum meal frequency during the previous day; plus (2) the proportion of non‐breastfed children 6–23 months of age who received at least two milk feedings and had at least the minimum dietary diversity and the minimum meal frequency during the previous day.

Independent variables

Independent variables were selected based on previously published studies. Independent variables were broadly classified into socio-demographic and economic-related factors, maternal health services-related factors, maternal knowledge-related factors, maternal autonomy-related factors, and agriculture-related factors.

Socio-demographic and economic factors included the age of the mother, age of the child, sex of child, religion, ethnicity, mother’s occupation, mother’s education, types of family, number of children, and wealth index [10]. The wealth index is a composite index calculated by using household assets. It was constructed by principal component analysis and categorized into first, 1; second,2; middle,3; fourth,4; and highest,5 [18]. Maternal health services-related information included the number of antenatal visits, postnatal visits, delivery place, types of delivery, growth monitoring, and nutritional counseling. Maternal knowledge-related variables included maternal knowledge on recommended feeding practices (first food, time of initiation of breast milk, frequency, variety, time to start semi-solid food, continuous breastfeeding). Agriculture-related variables included the production of crops, months enough for consumption, and home gardens [9,10]. Maternal autonomy included the decision-making power of mothers on the household decision (large household purchase and daily household needs), financial decision, child feeding, health care decision, and decision on mobility [19]. We constructed a nine-item questionnaire to assess the mother’s autonomy. Four of the nine questions were adopted from Nepal Demographic and Health Survey questionnaire. Five other questions were constructed based on the review of previous studies. The final questionnaire measured different dimensions of a mother’s autonomy including financial, child feeding, household related, healthcare-related as well as freedom of movement. Mothers were able to choose between five options ranging from 5 = decide by own self to 1 = decide by others. A continuous score was created by summing up the mother’s responses to individual questions. The total score was further categorized into tertiles (high, medium, and low). From pretesting, Cronbach’s alpha value of 0.84 was obtained for the mother autonomy scale, which indicated good internal consistency of the scale.

Statistical analysis

Data were cleaned, coded, and entered in EpiData. The entered data was exported to Statistical Package for Social Sciences (SPSS) version 21 for analysis. Data analysis was done in three stages. In the first stage, descriptive analyses (frequency and percentage) were used to report the dependent and independent variables. Frequency tables were used for categorical variables, while mean and standard deviation (SD) were calculated for continuous variables.

The second stage of analysis involved testing for the association of independent variables with infant and young child feeding practices. Chi-square statistics and p-value at a 95% level of confidence were reported. The third stage involved testing the strength of association between dependent and independent variables using binary logistic regression (Table in S3 File). All variables significant at 5% significance level in the Chi-square test were subjected to multivariate logistic regression analysis. Independent variables with a P-value <0.05 were entered into the multivariate analysis. The adjusted and unadjusted odds ratio with 95% confidence intervals were reported.

Data quality control

The choice of study design and methods suited for this study was decided based on the review of scientific literature. To ensure content validity, the questionnaire was developed based on study objectives and variables. To ensure tool validity, the standard questionnaire was used with necessary modifications. For respondent validity, face to face interview with the mother was conducted for data collection. Data collection was done by the researcher himself for less interpersonal variation and completeness of data. The tool was pretested in ward number 1 of Chapakot municipality, which was not selected for the study.

Ethical consideration

Approval was taken from the Institutional Review Committee of the Institute of Medicine and Central Department of Public Health, Tribhuvan University. Formal permission was also taken from the office of the respective urban and rural municipalities. The purpose and benefit of the study were clearly explained to the respondents and signed informed consent was obtained from the study participants before collecting data. Only participants who gave written or verbal consent took part in the study. Participation was strictly voluntary, and participants were free at any point in time to stop participation. Those participants who did not have adequate infant feeding practices were provided with the correct information and were advised to consult with health workers at any point of service outlets during data collection.

Results

General characteristics of study participants

Table 1 describes the socio-demographic characteristics of the study population. Out of 360 children, more than half (51.4%) were males. The age of study participants was between 15 to 40 years with a majority (40%) from the age group 25 to 29 years. Most children (71.4%) were from the age group 6 to 23 months. The mean age and SD of participants was 26.2 ± 4.1 years. More than half (54.7%) of participants were Brahmin/Chhettri and a majority (92.8%) of participants were Hindu. The majority (70%) of participants produced crops and was enough for 12 months.

Table 1

Distribution of participants by socio-demographic characteristics.

Characteristics	Number	Percentage
Sex of child
Female	175	48.6
Male	185	51.4
Mother age (years)
15–24	138	38.3
25–34	211	58.6
35 and above	11	3.1
Mean ± SD	26.2 ± 4.1
Children age (months)
0–5	103	28.6
6–23	257	71.4
Mean ± SD	10 ± 6.1
Ethnicity
Brahmin/chhetri	197	54.7
Janajati	99	27.5
Dalit	62	17.2
Thakuri	2	0.2
Family type
Nuclear	159	44.2
Joint	201	55.8
Religion
Hindu	334	92.8
Buddhist	23	6.4
Christian	3	.8
Education
Illiterate	16	4.4
Informal or primary	76	21.1
Secondary or above	268	74.4
Occupation
Agriculture	193	53.6
Housewife	69	19.2
Service	65	18
Business	33	9.2
Number of children
1	133	36.9
2	160	44.4
3	59	16.4
4 or more	8	2.2
Crop production and food security
No crop produced or not enough food for 12 months	108	30
Crop produced and enough food for 12 months	252	70

Distribution of participants by utilization of maternal health service-related information

Table 2 describes maternal health services utilization by mothers. Nearly half (49.7%) of participants took antenatal care services four or more times as per guidelines. Only 37.5% of participants went for post-natal services two or more times. A majority (83.3%) of mothers had delivered at the health facility. Three out of four (70.3%) participants took growth monitoring and promotion services and more than two out of five (44%) of participants received nutritional counseling from health workers.

Table 2

Distribution of participants by utilization of maternal health service.

Maternal health services	Number	Percentage
ANC visit
None	29	8.1
1 to 3 times	152	42.2
4 or more time	179	49.7
PNC visit
None	80	22.2
1 time	145	40.3
2 or more time	135	37.5
Place of delivery
Institution	300	83.3
Home	60	16.7
Types of delivery
Normal vaginal	322	89.4
Cesarean Section	38	10.6
Growth monitoring
Yes	253	70.3
No	107	29.7
Received nutrition counseling
Yes	161	44.7
No	199	55.3

Distribution of participants by their child feeding practice

Table 3 describes child feeding practices. A majority (95.6%) of participants fed breast milk to their children. Among them, more than two out of three (69.2%) of participants initiated breastfeeding immediately within an hour of childbirth. Less than half (47.6%) of children aged 0–5 months were exclusively breastfed. More than half (53.3%) of children aged 6–23 months were initiated with complementary feeding timely. Similarly, nearly half (49.4%) of children aged 6–23 months were fed according to recommended IYCF practice.

Table 3

Distribution of participants by their child feeding practices.

Feeding practices	Number	Percentage
Breastfeeding
Yes	344	95.6
No	16	4.4
Initiation of breastfeeding
Immediately within one hour	238	69.2
Within 1 to 24 hours	80	23.3
After 1 day	15	4.4
Do not know	11	3.2
Colostrum milk
Feed	312	90.7
Not feed	32	9.3
Breast milk substitute
Infant formula	11	68.8
Other milk	5	31.3
Exclusive breastfeeding
Not exclusive breastfeed	54	52.4
Exclusive breastfeed	49	47.6
Initiation of complementary feeding
Not timely initiation	120	46.7
Timely initiation	137	53.3
Minimum dietary diversity
Not met	99	38.5
Met	158	61.5
Minimum meal frequency
Not met	84	32.7
Met	173	67.3
Minimum acceptable diet
Not met	130	50.6
Met	127	49.4

The bivariate analysis has been reported separately as a supplementary file (Table in S3 File).

Factors associated with timely initiation of breastfeeding

Table 4 shows the factors associated with the timely initiation of breastfeeding. The result from the regression analysis showed that timely initiation of breastfeeding was more likely among mothers who delivered normally (AOR 10.7, 95% CI 4.5–25.3), belonged to the nuclear family (AOR 2.1,95% CI 1.2–3.5), and had correct knowledge on time of initiation of breastfeeding (AOR 9.1, 95% CI 3.5–23.6).

Table 4

Factors associated with timely initiation of breastfeeding.

Variables	Unadjusted OR	95% CI	P-value	Adjusted OR	95% CI	P-value
Type of delivery
Cesarean Section	Ref.			Ref.
Normal	9.3	4.0–21.4	<0.001*	10.7	4.5–25.3	<0.001*
Type of family
Joint	Ref.			Ref.
Nuclear	1.8	1.1–2.9	0.012*	2.1	1.2–3.5	0.006*
Knowledge on initiation of breastfeeding
Incorrect	Ref.			Ref.
Correct	7.2	2.9–17.7	<0.001*	9.1	3.5–23.6	<0.001

Note

* statistically significant at 95% level of confidence.

Factors associated with exclusive breastfeeding

Table 5 shows the factors associated with exclusive breastfeeding. The result from the regression analysis showed that exclusive breastfeeding was more likely among mothers who delivered through normal vaginal delivery (AOR 6.1, 95% CI 1.2–31.3) and mothers with the highest (AOR 5.2, CI 1.8–14.6) and middle (AOR 3.1, CI 1.0–9.2) level of autonomy.

Table 5

Factors associated with exclusive breastfeeding.

Variables	Unadjusted OR	95% CI	P-value	Adjusted OR	95% CI	P-value
Delivery type
CS	Ref.			Ref.
Normal	1.5	0.9–22.9	0.050	6.1	1.2–31.3	0.029*
Autonomy
Lowest	Ref.			Ref.
Middle	2.6	0.9–7.4	0.063	3.1	1.0–9.2	0.033*
Highest	4.5	1.6–12.5	0.003	5.2	1.8–14.6	0.002*

Note

* statistically significant at 95% level of confidence.

Factors associated with timely initiation of complementary feeding

Table 6 shows the factors associated with the timely initiation of complementary feeding. The result from regression analysis showed that timely initiation of complementary feeding was more likely for a male child (AOR 11.7, 95% CI 6.0–22.6) and mothers who received nutritional counseling (AOR 2.7, 95% CI 1.2–6.0). The result also shows that timely initiation of complementary feeding was less likely among mothers who had more children in their family (AOR 0.2, 95% CI 0.1–0.6).

Table 6

Factors associated with timely initiation of complementary feeding.

Variables	Unadjusted OR	95% CI	P-value	Adjusted OR	95% CI	P- value
Sex
Female	Ref			Ref
Male	8.0	4.6–14.1	<0.001	11.7	6.0–22.6	<0.001*
Child number
1	Ref			Ref
2	1.0	0.5–1.7	0.965	1.4	0.7–2.7	0.305
3	0.2	0.1–0.5	0.001	0.2	0.1–0.6	0.006*
4 or more	0.8	0.1–3.5	0.796	0.7	0.1–3.5	0.681
Delivery place
Home	Ref			Ref
Institution	2.1	1.0–4.2	0.028	1.8	0.7–4.4	0.154
Growth monitoring
No	Ref			Ref
Yes	1.8	1.1–3.2	0.018	1.1	0.5–2.5	0.756
Nutrition counseling
Not Received	Ref			Ref
Received	1.9	1.1–3.2	0.011	2.7	1.2–6.0	0.015*

Note

* statistically significant at 95% level of confidence.

Factors associated with minimum acceptable diet (MAD)

Table 7 shows the factors associated with a minimum acceptable diet. The result from the regression analysis showed that minimum acceptable diet was more likely for mother who produces crops and enough for 12 months (AOR 3.8, 95% CI 1.9–7.7), mothers who had correct knowledge on the minimum acceptable diet (AOR 2.5, 95% CI 1.0–6.2), mothers with middle (AOR 4.2, 95% CI 2.1–8.4) and higher (AOR 3.8, CI 1.8–7.7) level of autonomy.

Table 7

Factors associated with minimum acceptable diet.

Variables	Unadjusted OR	95% CI	P- value	Adjusted OR	95% CI	p- value
Crop production and food security
No crop produced or food not enough for 12 months	Ref			Ref
Crop produced and food enough for 12 months	4.3	2.2–8.3	<0.001	3.8	1.9–7.7	<0.001*
Delivery place
Home	Ref			Ref
Institution	2.1	1.0–4.2	0.028	1.3	0.5–3.3	0.526
PNC visit
None	Ref.			Ref.
1 time	2.1	1.0–4.2	0.030	1.2	0.5–3.0	0.587
2 or more times	2.3	1.1–4.6	0.016	1.3	0.5–3.3	0.562
Nutrition counseling
No	Ref.			Ref.
Yes	2.0	1.2–3.4	0.005	1.3	0.7–2.4	0.291
Knowledge on MAD
Incorrect	Ref.			Ref.
Correct	2.3	1.0–5.2	0.033	2.5	1.0–6.2	0.043*
Autonomy
Lowest	Ref.			Ref.
Middle	4.6	2.4–8.8	<0.001	4.2	2.1–8.4	<0.001*
Highest	3.5	1.8–6.8	<0.001	3.8	1.8–7.7	<0.001*

Note

* statistically significant at 95% level of confidence.

Discussion

Our study found that almost all children were breastfed, among them the majority of the children were initiate breastfeeding within one hour of delivery. The percentage of mothers who performed early initiation of breastfeeding in our study is comparable to a study conducted in central Nepal [20] but more than the national average of 54.9% reported by NDHS 2016, 48% reported by a recent national study [21], 57% reported in Bhaktapur [13] and 37.1% reported in Satar community Nepal [22]. Similarly, the rate is higher when compared with studies conducted in other South Asian countries like India (36.4%) [23], Bangladesh (24%) [24], Pakistan (8.5%) [25], Ethiopia (57.4) [26]. This might be due to increasing access to maternal health services, effective intervention, and commitments to promote breastfeeding through nutrition programs in Nepal. Our study showed a positive association between type of delivery, type of family, and maternal knowledge on the correct time of initiation of breastfeeding with timely initiation of breastfeeding. Similar findings were reported by other studies conducted in Nepal [27,28]. Timely initiation of breastfeeding was significantly higher among mothers who had a normal vaginal delivery. This finding was in agreement with the study conducted in India [29]. Longer procedure, pain following the procedure, severe bleeding, effects of anesthesia, and tiredness associated with caesarean delivery make it difficult to initiate breastfeeding early [30]. Similar to other studies from Bangladesh [24], Nepal [28], China [31], our study also found a positive association between timely initiation of breastfeeding and mother’s knowledge. Mother’s knowledge helps to adopt positive feeding practices. Mothers who were from nuclear family were more likely to initiate breastfeeding on time. A similar finding was reported from a study in Cartagena city of Colombia [32]. This might be due to children who live with nuclear family have high support for the mother to initiate breastfeeding. Focuses on improving delivery assistance at health institution, promotion of kangaroo mother care practices soon after delivery, provide counseling during antenatal care visit and improve maternal health care service utilizations would facilitate the timely initiation of breastfeeding.

In our study, the prevalence of exclusive breastfeeding was 47.6%, which was higher than the global average rate of 40% [33] and lower than the national average rate of 66% [34]. This finding was higher than the study conducted in the mid-western and eastern regions of Nepal [35] and slightly lower than the study conducted in rural southern Nepal [11]. This variation might be due small sample size compared to this study. We found mothers who delivered by cesarean section were less likely to exclusively breastfeed. This finding was consistent with the study conducted in India [36]. Our study also found that mothers with highest autonomy were more likely to exclusively breastfeed. This finding is similar to the studies conducted in Saharan Africa, south Asia and Latin America [37] in Vietnam [38]. Mothers with higher autonomy have higher decision-making capacity and they can decide themselves on matters related to child feeding, access to resource, utilization of health services, access to information and financial protection which ultimately improve the feeding practices.

In our study timely initiation of complementary feeding was 53.3% which was lower than the recent NDHS 2016 survey and similar to the other study conducted in other parts of the country [10,39]. Studies conducted in other developing countries like Bangladesh [40] and Ethiopia [41] also reported higher percentages (>60%) of complementary feeding at six months. Mothers who had more children were less likely to initiate complementary feeding at six months of age which was similar to findings from Hongkong [42] and Finland [43]. Mothers who received nutritional counseling were more likely to initiate complementary feeding on time. A similar finding was reported from a study in the Satar community [22]. Counseling mothers about complementary feeding during post-natal and growth monitoring phases has a favorable impact on the timely initiation of complementary feeding. Similarly, timely initiation of complementary feeding was significantly associated with the sex of children. Male children were more likely to have had timely initiation of complementary feeding. A similar finding was reported from a study conducted in other parts of Nepal [44] which reflects the long-standing traditional gender norm that discriminates against timely feeding of a female child [45].

In our study minimum dietary diversity, minimum meal frequency and minimum acceptable diet were 61.5%, 67.3%, and 49.4% respectively. These percentages are lower than the recent Nepal Demographic and Health Survey report. The percentage of minimum meal frequency was lower than the study conducted in the Terai region of Nepal which reported 84% of children meet minimum meal frequency [10]. This may be due to better access to maternal health services. A higher percentage of children met minimum dietary diversity in Sri Lanka 71% [26] and Bangladesh 81.1% [26] which may be because the majority of rural Nepalese communities depend on specific staple food available locally such as rice, wheat, and potato. Our study found that mothers who produced crops enough for 12 months were more likely to meet the minimum acceptable diet. A similar finding was reported by the further analysis of NDHS study 2016 [16]. Mothers who had correct knowledge on recommended feeding practices were more likely to meet the minimum acceptable diet [46]. Mothers with higher decision-making capacity were more likely to meet the minimum acceptable diet [47]. In our study mothers having middle autonomy had the best complementary feeding practices. A potential explanation might be that while low autonomy reduces women’s access to and control over resources in the household, the highest scores in autonomy might imply a lower level of partner support and thus more responsibility for women, which could reduce their caregiving capacity. Furthermore, women in the middle autonomy may be deciding jointly with their partners. This might reflect good relations and better communication between partners which might have resulted in better child complementary feeding practices. Others factors like antenatal visits, post-natal visits, wealth quintile, and the number of children are important determinants of child feeding practices in Nepal [20,27]. In our study these factors were not statistically associated due to variation in population size, setting, existing local traditions and beliefs. So further research with higher sample size and robust design is needed.

Some limitations need to be considered when interpreting the results of this study. WHO developed eight core indicators for assessing infant and young child feeding practices. In this study, only six indicators were used to assess the feeding practices of children. Two indicators i.e. consumption of iron rich or iron fortified food and continue breastfeeding for one-year age are not included in this study. Our study had less sample size for effective exclusive breastfeeding practices. Another limitation of this study was recall bias due to the retrospective nature of the data collection, possibly resulting in over or underestimation of actual feeding practices. Although recall biases cannot be avoided, the researcher conducted all interviews by asking probing questions to gather exact information. It should be also noted that epidemiological studies of this kind do not establish causality but may suggest associations. The use of already validated NDHS tools, WHO guidelines, indicators, and appropriate statistical adjustment are strengths of this study.

Conclusion

Our study presents important findings on infant and young child feeding practices and their associated maternal factors among mothers of under two years’ children in Syangja district of Nepal. Early initiation of breastfeeding was good but feeding according to recommended IYCF practice was poor (i.e., less than half). It is evident from this study that the factors such as maternal education, nutritional counseling, food security, child numbers, maternal health services, decision-making power were identified as key factors associated with feeding practices and these factors should be carefully considered when designing strategies and interventions.

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Conceptual framework.

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Bivariate analysis.

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23 Feb 2021

PONE-D-21-02451

Infant and young child feeding practices and its association with maternal factors among mothers of under two years children in western hilly region of Nepal

PLOS ONE

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4. We noticed you have some minor occurrence of overlapping text with the following previous publications, which needs to be addressed:

- "Associations between infant and young child feeding practices and diarrhoea in Indian children: a regional analysis" by Dhami et al., preprint posted 05 Feb 2020 (https://www.researchsquare.com/article/rs-13231/v1).

- "Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications" by Kavle et al., Public Health Nutrition Vol. 20(17), 2017 (https://www.cambridge.org/core/journals/public-health-nutrition/article/addressing-barriers-to-exclusive-breastfeeding-in-low-and-middleincome-countries-a-systematic-review-and-programmatic-implications/53EBA65F5D58D16E3E4D32E0FCFA938B).

- "Dietary diversity, meal frequency and associated factors among infant and young children in Northwest Ethiopia: a cross- sectional study" by Beyene et al., BMC Public Health 15, 2015 (https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2333-x).

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Congratulations on your article! It is notable that it required hard working.

Methods are detailed and make readers understand your trains of thought.

Results are clear, although it would be nice to show data about exclusive breastfeeding in children from 6-23 months. It would be interesting to check if the children exclusively breastfed at age 0-5 months had better feeding practices than children not breastfed. Besides, add information about how long these children were breastfeed would clarify feeding habits of the studied population and all social aspects involved.

Data shown on Table 3 relate to exclusive breastfeeding of the 103 children from 0-5 months. Data about the other 237 children would increase the interest on your article and would add relevant information to your research.

Discussion is well written and full of valid references. Comparing your data to data from countries with similar social issues enable readers to understand the range of your article.

Reviewer #2: Review

I am glad for the opportunity to review this manuscript. IYCF practice is very important issue for the context of most low and middle income countries. The main objective of this article is to associate the IYCF practices with maternal health care seeking practices. However, the plausible hypothetical association of maternal health care seeking practices with some of the distal IYCF practices is not well developed in the child nutrition literature.

According to my observations, there are several scientific drawbacks of this manuscript, especially in the conceptual framework formulation and Statistical analysis. Please see my detailed comments below.

Title page:

Line 5-24: The authorship order is bit confusing. The lead authorship, corresponding author and senior authorship is not clear. It would be better if the lead or senior author become the corresponding author. Moreover, the equal contribution in the middle is not clear to me. Equal contribution is mostly applicable for lead author and senior author.

Introduction

1. Line 54-55: When the complementary feeding should be started?

2. Line 61-66: Now it is 2021. Is there any updated data available? Please use the updated evidence throughout the Introduction section.

3. Line 61-72: Concise the write-up. The concept is repeating

4. Line 73-82: Why the autonomy was repeated and emphasized so much? But nothing told about the maternal care seeking practice indicators.

5. Line 73-85: The problem identification of necessities to explore the association maternal health seeking practice is not well defined. That means the rationale of the objective is not enough convincing.

Here the authors need to mention the available determinates found in the available similar literatures of Nepal and similar countries. Authors also need to find out at least one paper that explored the association of the maternal care seeking factors and child IYCF practices. If no specific paper found then the biological plausibility need to establish by the convincing argument. Hence, the conceptual framework needs to develop with the plausible independent factors. MNH practices could be one of the domains of conceptual framework and others factors will be the covariates/confounders.

Materials and methods

1. Line 98-99: Tell how many of districts 77 district are similar to Syangja and what is the total population of those similar district? Otherwise your sample only represents the limited 289,148 population of one district. Policy makers may not have the importance to the limited number of population. If possible then add a map.

2. Line 99: 1.164 km2 must be corrected.

3. Line 104-106: From how many rural and how many urban municipalities? Is rural administrative unit also called municipality in Nepal? What is the range of number of wards in municipalities?

4. Line 107-108: Not clear. What is proportionate to population size? Did authors make a list by themselves and randomly select the participants or something else? Please write what actually done there? Sometime the extensive sampling process may not possible to follow for the time and cost constraint. This could be a possible limitation of study.

5. Line 109-110: Add reference of minimum acceptable diet as 36% and total under two years children in Syangja district as 10524.

6. Line132-155: Please reduce the text. Only MAD was analyzed as main outcome variable. It is better to reduce text throughout outcome variable definitions.

7. Line 157-160: Need to add citation for all the independent variables. All the factors are the covariates/confounders between maternal health service factors and IYCF. It is better to move this part in Introduction and aligned with the conceptual framework formulation.

8. Line 174-176: How many researchers collected data? It is very difficult to conduct 360 interviews in 21 days by 1 person. What is the average time of interview?

9. Line 173-189: Move the data collection tools section before the variable section. If possible then aligned the text of both section and make one broad section named “Data collection tools and variables”. Firstly, write about tools. Then under this broad section, write outcome variables’ and independent variables’ sub section.

10. Line 206-209: VIF>10 is mostly useful for continuous independent variables. Please revisit other standard way for detecting multi-colinearity for categorical variables.

11. Line 219-220: Which indicators or scale was used to calculate this Cronbach’s alpha?

Results

1. Line 198-206 and line 258-291: I have some major observations in the data analysis. I think data analysis did not conducted properly as written in Statistical analysis section.

Here there are four main outcome variables and many independent variables. Firstly, chi-square test and bi-variate logistic regression need to do for each outcome variable with all relevant independent variables. Then all significant independent variables found in chi-square test or bi-variate logistic analysis need to insert in multivariate regression. You may consider the multi-collinearly or overlapping nature of independent variables. For all 4 outcomes, you have to repeat this analysis. The final interpretation should be based on adjusted analysis. Please see some format of other published articles. If you don’t want to put the elaborate analysis in the main manuscript then you can only put the result of adjusted analysis in the manuscript. But you have to put the elaborate analysis in a supplementary file.

My main concern is, some most important individual or household level determinants (e.g., mother age, education, employment, number of child/parity, wealth quintile, ethnicity, family type, food insecurity status, child age, sex etc) may not included in the bi-variate and multivariate analysis. For this reason, the effect sizes between bvariate and multivariate regression did not changed more. Please revise the full analysis.

2. Table 7: The crude OR and Adjusted OR for ANC and PNC reversed completely. There might be some problem in somewhere. Please consult with a public health statistical expert.

Discussion and conclusion

1. Based on the available result, the discussion and conclusion was well written. But full discussion and a conclusion may need to revise based on revised result.

2. My concluding remarks and suggestion to the authors is that if most of the maternal health utilization factors would not significant in the revised adjusted data analysis, then to change objective and title as general determinant exploration of IYCF practices.

**********

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Reviewer #1: No

Reviewer #2: Yes: Md. Rashidul Azad

Research Investigator,

Maternal and Child Health Division,

icddr,b

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29 Mar 2021

Reviewer #1: Congratulations on your article! It is notable that it required hard working.

Methods are detailed and make readers understand your trains of thought.

Results are clear, although it would be nice to show data about exclusive breastfeeding in children from 6-23 months. It would be interesting to check if the children exclusively breastfed at age 0-5 months had better feeding practices than children not breastfed. Besides, add information about how long these children were breastfeed would clarify feeding habits of the studied population and all social aspects involved. Data shown on Table 3 relate to exclusive breastfeeding of the 103 children from 0-5 months. Data about the other 237 children would increase the interest on your article and would add relevant information to your research.

Response- Thank you for your comments. As per assessment tools for infant and young child feeding practices we can assess the exclusive breastfeeding of 0-5 months children only so this tools is not valid to assess exclusive breastfeeding in children from 6-23 months.

Discussion is well written and full of valid references. Comparing your data to data from countries with similar social issues enable readers to understand the range of your article.

Response- Thank you for the comment. We have added relevant references.

Reviewer #2: Review

Title page:

Line 5-24: The authorship order is bit confusing. The lead authorship, corresponding author and senior authorship is not clear. It would be better if the lead or senior author become the corresponding author. Moreover, the equal contribution in the middle is not clear to me. Equal contribution is mostly applicable for lead author and senior author.

Response- Thank you for the comment. We have amended the order of authorship.

Introduction

1. Line 54-55: When the complementary feeding should be started?

Response- Complementary feeding should be started after six months of age. We have mentioned it now on final version of manuscript.

2. Line 61-66: Now it is 2021. Is there any updated data available? Please use the updated evidence throughout the Introduction section.

Response- Thank you for the comment. We have now updated the data.

3. Line 61-72: Concise the write-up. The concept is repeating

Response- Thank you for the comment. We have shortened it.

4. Line 73-82: Why the autonomy was repeated and emphasized so much? But nothing told about the maternal care seeking practice indicators.

Response-Thank you for the comment. We have now included maternal care seeking related evidence from Nepal.

5. Line 73-85: The problem identification of necessities to explore the association maternal health seeking practice is not well defined. That means the rationale of the objective is not enough convincing.

Response- Thank you for the comment. We have explored the evidence related to maternal health services and infant and young child feeding practices.

Here the authors need to mention the available determinates found in the available similar literatures of Nepal and similar countries. Authors also need to find out at least one paper that explored the association of the maternal care seeking factors and child IYCF practices. If no specific paper found then the biological plausibility need to establish by the convincing argument. Hence, the conceptual framework needs to develop with the plausible independent factors. MNH practices could be one of the domains of conceptual framework and others factors will be the covariates/confounders.

Response- Thank you for the comment. We have explored the evidence related to maternal health services and infant and young child feeding practices and provided two references (Reference 6 and 7) for the same. Conceptual framework attached as supplementary file S5.

Materials and methods

1. Line 98-99: Tell how many of districts 77 district are similar to Syangja and what is the total population of those similar district? Otherwise your sample only represents the limited 289,148 population of one district. Policy makers may not have the importance to the limited number of population. If possible then add a map.

Response- Thank you for the comment. Syangja district is one of the 20 hilly districts of Nepal. Our country has been divided into three ecological zone (i.e. mountain, hill, and terai) based on geographical situation and seventy-seven district based on population size, geographical location. About 45 percent of total population of Nepal live in the hilly districts and we have mentioned this in the methods.

2. Line 99: 1.164 km2 must be corrected.

Response- Thank you. We have corrected it.

3. Line 104-106: From how many rural and how many urban municipalities? Is rural administrative unit also called municipality in Nepal? What is the range of number of wards in municipalities?

Response- Thanks for the comment. Altogether there are five urban municipalities and six rural municipalities in Syangja district. Rural administrative unit also called as rural municipality in Nepal. A ward is the smallest administrative unit in Nepal and number of wards in a municipality ranges from minimum of five to maximum of 33. We have mentioned this is the methods.

4. Line 107-108: Not clear. What is proportionate to population size? Did authors make a list by themselves and randomly select the participants or something else? Please write what actually done there? Sometime the extensive sampling process may not possible to follow for the time and cost constraint. This could be a possible limitation of study.

Response- Thank you for the comment. Proportionate to population size is method of sampling in which required number of samples was identified based on proportion of sample where the probability of selecting a unit is proportional to its size. Authors had access to list of under two years children from health post of the ward and records from female community health volunteers. Author used this list as a sample frame. Regarding municipalities and ward, authors had access to list of municipalities and wards from Provincial Administrative Office.

5. Line 109-110: Add reference of minimum acceptable diet as 36% and total under two years children in Syangja district as 10524.

Response- Thank you for the comment. Reference has been added.

6. Line132-155: Please reduce the text. Only MAD was analyzed as main outcome variable. It is better to reduce text throughout outcome variable definitions.

Response- Thank you for the comment. We have done it.

7. Line 157-160: Need to add citation for all the independent variables. All the factors are the covariates/confounders between maternal health service factors and IYCF. It is better to move this part in Introduction and aligned with the conceptual framework formulation.

Response- Thank you for the comment. We have done this.

8. Line 174-176: How many researchers collected data? It is very difficult to conduct 360 interviews in 21 days by 1 person. What is the average time of interview?

Response- Thank you for your comment. Data collection team included five trained enumerators and author himself. Average time to taken interview was 45 min. We have mentioned this in the tools section.

9. Line 173-189: Move the data collection tools section before the variable section. If possible then aligned the text of both section and make one broad section named “Data collection tools and variables”. Firstly, write about tools. Then under this broad section, write outcome variables’ and independent variables’ sub section.

Response- Thank you for the comment. We have done accordingly.

10. Line 206-209: VIF>10 is mostly useful for continuous independent variables. Please revisit other standard way for detecting multi-colinearity for categorical variables.

Response- Thank you for the comment. We used Chi square test for categorical variables, and all variables significant at 5% level of significance in bivariate analysis were considered for multivariate analysis.

11. Line 219-220: Which indicators or scale was used to calculate this Cronbach’s alpha?

Response- Thank you for the comment. To check internal consistency in the mother’s autonomy scale, Cronbach’s alpha was used.

Results

1. Line 198-206 and line 258-291: I have some major observations in the data analysis. I think data analysis did not conducted properly as written in Statistical analysis section.

Here there are four main outcome variables and many independent variables. Firstly, chi-square test and bi-variate logistic regression need to do for each outcome variable with all relevant independent variables. Then all significant independent variables found in chi-square test or bi-variate logistic analysis need to insert in multivariate regression. You may consider the multi-collinearly or overlapping nature of independent variables. For all 4 outcomes, you have to repeat this analysis. The final interpretation should be based on adjusted analysis. Please see some format of other published articles. If you don’t want to put the elaborate analysis in the main manuscript then you can only put the result of adjusted analysis in the manuscript. But you have to put the elaborate analysis in a supplementary file. My main concern is, some most important individual or household level determinants (e.g., mother age, education, employment, number of child/parity, wealth quintile, ethnicity, family type, food insecurity status, child age, sex etc) may not included in the bi-variate and multivariate analysis. For this reason, the effect sizes between bvariate and multivariate regression did not changed more. Please revise the full analysis.

Response- Thank you for the comment. We have included bivariate analysis as supplementary file (S6).

2. Table 7: The crude OR and Adjusted OR for ANC and PNC reversed completely. There might be some problem in somewhere. Please consult with a public health statistical expert.

Response- Thank you for the comment. We have revised the analysis.

Discussion and conclusion

1. Based on the available result, the discussion and conclusion was well written. But full discussion and a conclusion may need to revise based on revised result.

Response- Thank you for the comment. Discussion and conclusion have been revised.

2. My concluding remarks and suggestion to the authors is that if most of the maternal health utilization factors would not significant in the revised adjusted data analysis, then to change objective and title as general determinant exploration of IYCF practices.

Response- Thank you for the comment. Factors such as maternal education, maternal health service utilization, maternal knowledge, decision making power are still significantly associated with IYCF practices in revised data analysis.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

7 May 2021

PONE-D-21-02451R1

Infant and young child feeding practices and its association with maternal factors among mothers of under two years children in western hilly region of Nepal

PLOS ONE

Dear Dr. Pradhan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

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Associate Editor

on behalf of

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Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Congratulontions on your article!

After the suggested changes it is clear and cohesive. Unfortonately missing data could not be included, what could have added more relevance.

The added references made the difference in the discussion.

Reviewer #2: Thanks for submitting the 1st revision of the manuscript. After careful consideration of the result of bivarite and multivariate analysis, and other supplementary materials, I think some additional revision is required to meet the adequate standard of a scientific manuscript. I suggested that authors should review some systematic review of IYCF practices, especially enablers and barriers of IYCF practices in the relevant context. The reflection of these systematic reviews is required throughout the whole manuscript. Authors need to do possible modification wherever possible otherwise need to mention as limitations. I am mentioning some of my specific observations below,

Title

Throughout the manuscript, especially the Result and Discussion, I do not find any special reflection of maternal factors on all IYCF practices. So, I suggest not to use maternal factors in the title, rather mentioning about general determinants or factors of IYCF in western hilly region of Nepal.

Abstract

Authors need to revise Abstract according to overall revision of manuscript.

Introduction

1. Line 83-89: Please omit the special importance of maternal factors and make it general. Focus on the rationale of IYCF exploration in the hilly area of Nepal.

Materials and methods

1. Sampling: Generally in Multistage sampling, PPS was done to select 1st stage cluster (municipality), and in second stage fixed number of sample is taken from each 1st stage cluster. This is self weighting sampling and having some statistical advantage. But authors did the opposite (missed to take a statistical opportunity). No matter what, please write, how many rural and urban municipalities are in the Syangja district?

2. Line 122-28: The details of maternal autonomy questionnaire need to incorporate in “Independent variables” section.

3. Maternal knowledge on feeding practice: How the low, medium and high knowledge is categorized? A combined score of maternal knowledge on different child feeding practice at different age may not have the causal temporal relationship with all IYCF practice. For example, knowledge of breastfeeding may not plausibly improve the dietary diversity practice. So, I suggest not to create a combined knowledge score, rather use them independently as separate independent variable whereas applicable in relevant analysis table.

4. Statistical analysis: Refer S6 (Bivariate analysis final) and also tell that the variable found significant in chi-square test included in bivariate and multivariate logistic regression.

5. Line 196-97: Drop the sentence “Multi-collinearity was assessed before performing logistic regression by Chi-square test”. Multi-collinearity is not problem here because a few independent variables found significant at first stage.

Results

1. Authors need to make some more categories of education for understanding the doge response relationship. Make at least 3 categories of consistent with Nepal DHS or other similar literature of Nepal. Why the informal education comes as a separate category? Primarily, I am suggesting 4 categories, i.e., illiterate, informal+primary, secondary, and higher secondary or above. Authors could explore different ordered categories. Also use same education category for all outcome variables’ table.

2. Authors need to use the frequency of ANC as category for understanding the doge response. For example, 0 ANC, 1-3 ANC, 4-6 ANC and 7+ANC. Existing literatures emphasized the relationship of ANC number and IYCF practices more.

3. Authors should try to use same independent variables wherever applicable for all the tables of S6 (Bivariate analysis final). In table 2 of S6, Sex of the child must be included.

4. Birth order of last child is an important determinant of most of IYCF practices. Number of child could be a proxy of birth order. The number of child should be re-categorized as 1, 2, 3 and 4+.

5. The order of Yes/No column of all tables of S6 should be unique.

6. Some important determinants of IYCF were not included in the analysis. For example, preterm birth, perceived size of child, lower birth order, parity, household food security, father’s education, maternal employment, exposure to media, family level health promoter’s visit for IYCF promotion and IYCF specific counseling and knowledge development (i.e., whether mother received counseling on timely initiation of breastfeeding, exclusive breastfeeding, timely initiation of complementary feeding, dietary diversity and age specific meal frequency; and whether mother developed the specific knowledge of specific IYCF practice). Not all of these indicators were collected in the survey, but some of their proxy can be used. Authors should mention the reasons for not collecting these important variables in the limitation section and also need to write about the way out using the proxy variables.

7. How “Food enough to eat for” variable used in the multivariate analysis. This variable is only applicable for if “Crop production” is Yes. “Crop production” is No will make pair-wise case deletion in the multivariate analysis. Authors could make a composite indicator named “Crop production and food security”. Indicator option: 1. Not produce crop or food not enough for 12 months, 2. Produced crop and food enough for 12 months

8. Maternal occupation should be categorized as standard order of maternal employment.

9. The effective sample size of exclusive breastfeeding analysis is low. Authors need to write in limitation section.

10. Line 232-33 in 1st revised version: 91.9% become duplicated.

11. Line 238-43: Write the applicable age range of child.

12. Table 4, 5, 6 and 7: Add p-value of Crude OR.

13. Table 4, 5, 6 and 7: Write uniquely Crude OR or Unadjusted OR, also Explanatory variable or Variable.

14. For Crude OR, Adjusted OR and 95% CI, use 1 digit decimal rounding; and for p-value, use 3 digit decimal rounding. Adequate rounding will help the readers to follow easily.

15. Table 6: The crude OR of Growth monitoring and Nutrition counseling need to recheck and corrected. This is not matching with the proportion of bivariate analysis of S6.

16. Table 7: The crude OR of PNC visit also need to recheck and corrected. This is also not matching with the proportion of bivariate analysis of S6.

17. Line 248-78: Table 4, 5, 6 and 7 are the subsequent analysis of S6. At the beginning of write-up, authors need to add an introductory paragraph noting the analysis sequence of S6 to Table 4, 5, 6 and 7.

Discussion

In discussion, the reflection of all IYCF papers conducted in Nepal must be included. I found some more IYCF papers of Nepal than authors referenced in the discussion. The reasons of similarity or dissimilarity of the result should be convincingly interpreted. Next to the Nepalese IYCF literatures, authors should consider the IYCF papers of South Asian countries, and then if required, need to consider the African, Latin American and East asian context. Authors should explore the recent systematic reviews of South Asian countries. Some of my specific comments of discussion are,

1. From my knowledge, there are sufficient contextual differences among the geographical regions of Nepal, and the context of this study is especially focused in western hilly area. If all region of Nepal is similar then there is no need of this separate study. So, in comparison and result interpretation the differential contextual issue always needs to keep in mind. The result interpretation and programmatic recommendation always need to be concentrated in western hilly area of Nepal.

2. Line 280-85: The sample size of currently breastfeeding and timely initiation of breastfeeding is not less. What is the programmatic implication of such high rate of breastfeeding in the hilly area of Nepal or Nepal in general? Is this normal secular trend? Is the current government and non-government policy and program is doing well? Is there any future programmatic recommendation? Review more relevant literatures and add logical insight.

3. Authors also need to discuss about the proportion of Initiation of complementary feeding, Minimum dietary diversity and Minimum acceptable diet. Authors also need to generate some programmatic recommendations.

4. Line 286-94: Compare the results with Nepal’s literatures first, then the country of South Asia, if unavailable then can be compared with other countries. What is the reason that nuclear family more likely to initiate breastfeeding on time? Did the Colombian study mention any reason?

5. Line 295-98: Lower than the national average may be only due the low sample size. Were the Cameroon and North West Ethiopia’s studies’ EBF prevalence also lower than their National EBF prevalence? If yes then this reference can be used, otherwise need to delete. The language also need to change, so that we can be understood the similarly of situation that the studies encountered similarly.

6. Line 314-325: Reduce the text. Drop the similar sentence. Inverse association need not to mention here. If mentioned then the reason also need to mention. “Mothers with higher autonomy received more advice about optimal breastfeeding while attending antenatal care.”—Is this really true? How is it? Add reference. Otherwise delete.

7. Line 326-33: Wealth quintile is most important factor found of timely initiation of complementary feeding in most of the similar literature. Why wealth quintile is not a factor for this target population? Authors need to try to explain.

8. Line 332-33: “Considering the sociocultural practices of Nepalese society, female children are introduced early with complementary feeding.”---Need correction

9. Line 334-51: The non-association of wealth quintile needs to explain. The negative association of maternal autonomy of Benin and Nigeria need not to mention.

10. Line 299-351: In addition to the comparing result and interpretation, some practical and feasible way forward recommendations for nutrition policy, programming and intervention for Nepal or hilly area of Nepal are required. Authors need to include some specific way forward recommendations.

Conclusion

1. The summary of specific recommendations of discussion need to include in Conclusion section.

2. Finally, after the revision, I suggest a 3rd person’s language edit to improve the standard of language.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Rashidul Azad, Research Investigator, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

28 Jun 2021

Reviewer #1: Congratulontions on your article!

After the suggested changes it is clear and cohesive. Unfortonately missing data could not be included, what could have added more relevance.

The added references made the difference in the discussion.

Reviewer #2: Thanks for submitting the 1st revision of the manuscript. After careful consideration of the result of bivarite and multivariate analysis, and other supplementary materials, I think some additional revision is required to meet the adequate standard of a scientific manuscript. I suggested that authors should review some systematic review of IYCF practices, especially enablers and barriers of IYCF practices in the relevant context. The reflection of these systematic reviews is required throughout the whole manuscript. Authors need to do possible modification wherever possible otherwise need to mention as limitations. I am mentioning some of my specific observations below,

Title

Throughout the manuscript, especially the Result and Discussion, I do not find any special reflection of maternal factors on all IYCF practices. So, I suggest not to use maternal factors in the title, rather mentioning about general determinants or factors of IYCF in western hilly region of Nepal.

Response: Thank you for your comments. We have modified the title accordingly.

Abstract

Authors need to revise Abstract according to overall revision of manuscript.

Response: We have revised the abstract according to revised manuscript.

Introduction

1. Line 83-89: Please omit the special importance of maternal factors and make it general. Focus on the rationale of IYCF exploration in the hilly area of Nepal.

Materials and methods

Response: Thank you for the comment. We have modified the introduction accordingly.

1. Sampling: Generally in Multistage sampling, PPS was done to select 1st stage cluster (municipality), and in second stage fixed number of sample is taken from each 1st stage cluster. This is self weighting sampling and having some statistical advantage. But authors did the opposite (missed to take a statistical opportunity). No matter what, please write, how many rural and urban municipalities are in the Syangja district?

Response: Thank you very much for the comments. We have already mentioned in methodology that Syangja district has 5 urban municipalities and 6 rural municipalities.

2. Line 122-28: The details of maternal autonomy questionnaire need to incorporate in “Independent variables” section.

Response : Thank you very much for your comments. We incorporated it in independent variables section.

3. Maternal knowledge on feeding practice: How the low, medium and high knowledge is categorized? A combined score of maternal knowledge on different child feeding practice at different age may not have the causal temporal relationship with all IYCF practice. For example, knowledge of breastfeeding may not plausibly improve the dietary diversity practice. So, I suggest not to create a combined knowledge score, rather use them independently as separate independent variable whereas applicable in relevant analysis table.

Response: Thank you very much for your comments. We have incorporated your suggestion.

4. Statistical analysis: Refer S6 (Bivariate analysis final) and also tell that the variable found significant in chi-square test included in bivariate and multivariate logistic regression.

Response: Thank you for your comments. We have mentioned this in statistical analysis section.

5. Line 196-97: Drop the sentence “Multi-collinearity was assessed before performing logistic regression by Chi-square test”. Multi-collinearity is not problem here because a few independent variables found significant at first stage.

Response: Thank you for your comment. We have addressed this now.

Results

1. Authors need to make some more categories of education for understanding the doge response relationship. Make at least 3 categories of consistent with Nepal DHS or other similar literature of Nepal. Why the informal education comes as a separate category? Primarily, I am suggesting 4 categories, i.e., illiterate, informal+primary, secondary, and higher secondary or above. Authors could explore different ordered categories. Also use same education category for all outcome variables’ table.

Response: Thank you for your comments. We have addressed the comment. We have also used same categories of education in bivariate and multivariate analysis.

2. Authors need to use the frequency of ANC as category for understanding the doge response. For example, 0 ANC, 1-3 ANC, 4-6 ANC and 7+ANC. Existing literatures emphasized the relationship of ANC number and IYCF practices more.

Response: Thank you so much for your comments. We have categorized the variable as per your suggestion and used the same in bivariate and multivariate analysis.

3. Authors should try to use same independent variables wherever applicable for all the tables of S6 (Bivariate analysis final). In table 2 of S6, Sex of the child must be included.

Response: Thank you for your comment. It has been addressed.

4. Birth order of last child is an important determinant of most of IYCF practices. Number of child could be a proxy of birth order. The number of child should be re-categorized as 1, 2, 3 and 4+.

Response: Thank you for your comment. It has been re-categorized.

5. The order of Yes/No column of all tables of S6 should be unique.

Response: Thank you so much for your comment. It has been addressed.

6. Some important determinants of IYCF were not included in the analysis. For example, preterm birth, perceived size of child, lower birth order, parity, household food security, father’s education, maternal employment, exposure to media, family level health promoter’s visit for IYCF promotion and IYCF specific counseling and knowledge development (i.e., whether mother received counseling on timely initiation of breastfeeding, exclusive breastfeeding, timely initiation of complementary feeding, dietary diversity and age specific meal frequency; and whether mother developed the specific knowledge of specific IYCF practice). Not all of these indicators were collected in the survey, but some of their proxy can be used. Authors should mention the reasons for not collecting these important variables in the limitation section and also need to write about the way out using the proxy variables.

Response: Thank you for your comments. We have addressed this in limitations.

7. How “Food enough to eat for” variable used in the multivariate analysis. This variable is only applicable for if “Crop production” is Yes. “Crop production” is No will make pair-wise case deletion in the multivariate analysis. Authors could make a composite indicator named “Crop production and food security”. Indicator option: 1. Not produce crop or food not enough for 12 months, 2. Produced crop and food enough for 12 months

Response: Thank you so much for your comments. This has been addressed accordingly.

8. Maternal occupation should be categorized as standard order of maternal employment.

Response: Thank you so much for your comment. We have classified the occupation accordingly.

9. The effective sample size of exclusive breastfeeding analysis is low. Authors need to write in limitation section.

Response: Thank you for your comment. We have mentioned it as limitation.

10. Line 232-33 in 1st revised version: 91.9% become duplicated.

Response: Thank you for your comment. This has been corrected.

11. Line 238-43: Write the applicable age range of child.

Response: Thank you for your comment. The standard age categories to assess infant feeding practices was used

12. Table 4, 5, 6 and 7: Add p-value of Crude OR.

Response: Thank you for your comment. We have added it.

13. Table 4, 5, 6 and 7: Write uniquely Crude OR or Unadjusted OR, also Explanatory variable or Variable.

Response: Thank you for your comments. We have now written it accordingly.

14. For Crude OR, Adjusted OR and 95% CI, use 1 digit decimal rounding; and for p-value, use 3 digit decimal rounding. Adequate rounding will help the readers to follow easily.

Response: Thank you for the comment. We have corrected it.

15. Table 6: The crude OR of Growth monitoring and Nutrition counseling need to recheck and corrected. This is not matching with the proportion of bivariate analysis of S6.

Response: Thank you for your comment. We have addressed it.

16. Table 7: The crude OR of PNC visit also need to recheck and corrected. This is also not matching with the proportion of bivariate analysis of S6.

Response: Thank you for your comment. We have addressed it.

17. Line 248-78: Table 4, 5, 6 and 7 are the subsequent analysis of S6. At the beginning of write-up, authors need to add an introductory paragraph noting the analysis sequence of S6 to Table 4, 5, 6 and 7.

Response: Thank you for your comment. We have added a line in the results section.

Discussion

In discussion, the reflection of all IYCF papers conducted in Nepal must be included. I found some more IYCF papers of Nepal than authors referenced in the discussion. The reasons of similarity or dissimilarity of the result should be convincingly interpreted. Next to the Nepalese IYCF literatures, authors should consider the IYCF papers of South Asian countries, and then if required, need to consider the African, Latin American and East asian context. Authors should explore the recent systematic reviews of South Asian countries. Some of my specific comments of discussion are,

1. From my knowledge, there are sufficient contextual differences among the geographical regions of Nepal, and the context of this study is especially focused in western hilly area. If all region of Nepal is similar then there is no need of this separate study. So, in comparison and result interpretation the differential contextual issue always needs to keep in mind. The result interpretation and programmatic recommendation always need to be concentrated in western hilly area of Nepal.

Response: Thank you for your comment. We have modified it accordingly.

2. Line 280-85: The sample size of currently breastfeeding and timely initiation of breastfeeding is not less. What is the programmatic implication of such high rate of breastfeeding in the hilly area of Nepal or Nepal in general? Is this normal secular trend? Is the current government and non-government policy and program is doing well? Is there any future programmatic recommendation? Review more relevant literatures and add logical insight.

Response: Thank you for your comment. We have modified it accordingly

3. Authors also need to discuss about the proportion of Initiation of complementary feeding, Minimum dietary diversity and Minimum acceptable diet. Authors also need to generate some programmatic recommendations.

Response: Thank you for your comment. We have modified it accordingly

4. Line 286-94: Compare the results with Nepal’s literatures first, then the country of South Asia, if unavailable then can be compared with other countries. What is the reason that nuclear family more likely to initiate breastfeeding on time? Did the Colombian study mention any reason?

Response: Thank you for your comment. We have modified it accordingly

5. Line 295-98: Lower than the national average may be only due the low sample size. Were the Cameroon and North West Ethiopia’s studies’ EBF prevalence also lower than their National EBF prevalence? If yes then this reference can be used, otherwise need to delete. The language also need to change, so that we can be understood the similarly of situation that the studies encountered similarly.

Response: Thank you for your comment. We have modified it accordingly

6. Line 314-325: Reduce the text. Drop the similar sentence. Inverse association need not to mention here. If mentioned then the reason also need to mention. “Mothers with higher autonomy received more advice about optimal breastfeeding while attending antenatal care.”—Is this really true? How is it? Add reference. Otherwise delete.

Response: Thank you for your comment. We have modified it accordingly

7. Line 326-33: Wealth quintile is most important factor found of timely initiation of complementary feeding in most of the similar literature. Why wealth quintile is not a factor for this target population? Authors need to try to explain.

Response: Thank you for your comment. We have modified it accordingly

8. Line 332-33: “Considering the sociocultural practices of Nepalese society, female children are introduced early with complementary feeding.”---Need correction

Response: Thank you for your comment. We have corrected it.

9. Line 334-51: The non-association of wealth quintile needs to explain. The negative association of maternal autonomy of Benin and Nigeria need not to mention.

Response: Thank you for your comment. We have modified it accordingly

10. Line 299-351: In addition to the comparing result and interpretation, some practical and feasible way forward recommendations for nutrition policy, programming and intervention for Nepal or hilly area of Nepal are required. Authors need to include some specific way forward recommendations.

Response: Thank you for your comment. We have modified it accordingly

Conclusion

1. The summary of specific recommendations of discussion need to include in Conclusion section.

Response: Thank you for your comment. We have modified it accordingly

2. Finally, after the revision, I suggest a 3rd person’s language edit to improve the standard of language.

Response: Thank you for your comment. Language editing has been performed.

Submitted filename: Response to reviewer 28.06.21.docx

Click here for additional data file.

28 Sep 2021

PONE-D-21-02451R2

Infant and young child feeding practices and its associated factors among mothers of under two years children in a western hilly region of Nepal

PLOS ONE

Dear Dr. Pradhan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

A few minor edits have been requested by the reviewers to further improve the language of your manuscript. Please see the attached reviewer comments for specific locations in the manuscript that require further attention. Thank you for your continued efforts on this exciting paper on early life feeding.

Please submit your revised manuscript by Nov 07 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Congratulations on your paper!

Feeding pratices is a very important theme, specially in low income countries, and we should have more studies in this field.

You did some language improvements. Your text is more concise and your writting is clearer. Introduction is straight foward. Methods are precise. Results are clean and related to the tables. Discussion has relevant references and more cohesive.

The only typing error is in line 304, after ref 33. Probably there is missing a comma or a preposition.

Reviewer #2: Thanks authors for submitting the 2nd revised version. Congratulations for your hard work. I have few minor comments need to address before publication. In addition to that an external person’s final language checking of the unspotted errors would improve the overall language quality of manuscript.

Introduction

1. Line 55-56: “Appropriate infant and young child feeding practices help to prevent almost of all under-five deaths.” --- Please add citation with appropriate reference.

2. Line 65-66: “The government of Nepal has developed and implemented different acts, policies, strategies, and programs to improve infant feeding practices.” --- Please add citation with appropriate reference.

3. Line 75-67: “Maternal factors such as decision-making capacity, education, knowledge, and maternal health services utilization are important factors for child feeding practices.” --- Please add citation with appropriate reference.

4. Line 81-83: Write in simple language mentioning the prevalence of plain and hilly area. Your sentence structure sounds that prevalence of hilly area is lower than plain area!

Materials and methods

1. Line 96-101: Difficult to follow. Write hierarchical and simple language.

2. Line 171-174: Add score of reliability of scale here not in Data Quality control section.

Results

1. Line 214: “26.20 ± 4.148”--- Make 1 decimal point. Do it throughout manuscript except p-value.

2. Line 229-30: “Less than half (47.6%) of children were exclusively breastfed.” --- Mention the age range of denominator of this proportion for better understanding.

3. Line 230-31: “More than half (53.3%) of children were initiated with complementary feeding timely. Similarly, nearly half (49.4%) of children were fed according to recommended.” --- Mention the age range of denominator of this proportion for better understanding.

4. “Instutional” spelling should be corrected in Table 6 and Table 7.

Discussion

1. Line 284-86: “This would suggest that more efforts are needed on improving the quality of maternal and neonatal health care services at health institutions.”--- What kind of effort can be given to initiate breastfeeding within one hour after delivery?

2. Line 288-88: “Mothers who were from nuclear family were more likely to initiate breastfeeding on time.”--- Please explain why

3. Line 294-96: “This variation might be due to the socio-economic status of the participants, access to a health facility, and sample size compared to this study.”--- This effective sample size of EBF is 103. This small sample size is incapable to capture variation socio-economic status and access to a health facility. So, emphasize the small sample size as only limiting factor and discard socio-conomic status and access to the health facility.

4. Line 298-302: By definition of EBF is considered 24 hours before interview. How these facility level speculations are linked with EBF within last 24 hours?

5. Line 296-308: The factor determination of EBF is seriously flawed by the small sample size. So, extended discussion and stronger recommendation is not applicable. For EBF, I only prefer mentioning the result and telling the consistency of literature in similar settings. IF inconsistent findings found then tell about the small sample size as a probable reason.

6. Line 343-45: Recommendation of further research need to add with the higher sample size (especially for the narrower age range) with other applicable robust designs.

7. Line 346-47: “In this study, only six indicators were used to assess the feeding practices of children.”--- Is there any more WHO indicators to assess the IYCF? Mention about the independent variables that you missed in the questionnaire.

Conclusion

1. Line 362-64: “We also need to address the service quality and utilization of maternal health services which is considered to be an important determinant of child feeding practices.”--- In this study service quality is not measured.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Md. Rashidul Azad,

Research Investigator,

icddr,b, Bnagladesh

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

6 Nov 2021

Introduction

1. Line 55-56: “Appropriate infant and young child feeding practices help to prevent almost of all under-five deaths.” --- Please add citation with appropriate reference.

Response – Thank you so much for your comment. We added the citation.

2. Line 65-66: “The government of Nepal has developed and implemented different acts, policies, strategies, and programs to improve infant feeding practices.” --- Please add citation with appropriate reference.

Response – Thank you so much for your comment. We added the citation.

3. Line 75-67: “Maternal factors such as decision-making capacity, education, knowledge, and maternal health services utilization are important factors for child feeding practices.” --- Please add citation with appropriate reference.

Response – Thank you so much for your comment. We added the citation.

4. Line 81-83: Write in simple language mentioning the prevalence of plain and hilly area. Your sentence structure sounds that prevalence of hilly area is lower than plain area!

Response – Thank you so much for your comments. We have written it in simple language.

Materials and methods

1. Line 96-101: Difficult to follow. Write hierarchical and simple language.

Response – Thank you so much for your comments. We have now made it clear.

2. Line 171-174: Add score of reliability of scale here not in Data Quality control section.

Results

Response – Thank you so much for your comments. We added reliability score.

1. Line 214: “26.20 ± 4.148”--- Make 1 decimal point. Do it throughout manuscript except p-value.

Response – Thank you so much for your comments. We have corrected it.

2. Line 229-30: “Less than half (47.6%) of children were exclusively breastfed.” --- Mention the age range of denominator of this proportion for better understanding.

Response – Thank you so much for your comments. We have added the age range.

3. Line 230-31: “More than half (53.3%) of children were initiated with complementary feeding timely. Similarly, nearly half (49.4%) of children were fed according to recommended.” --- Mention the age range of denominator of this proportion for better understanding.

Response – Thank you so much for your comments. We added the age range.

4. “Instutional” spelling should be corrected in Table 6 and Table 7.

Response – Thank you so much for your comments. We have corrected it.

Discussion

1. Line 284-86: “This would suggest that more efforts are needed on improving the quality of maternal and neonatal health care services at health institutions.”--- What kind of effort can be given to initiate breastfeeding within one hour after delivery?

Response – Thank you so much for your comments. We have added the points in discussion.

2. Line 288-88: “Mothers who were from nuclear family were more likely to initiate breastfeeding on time.”--- Please explain why

Response – Thank you so much for your comments. We have added the possible reason.

3. Line 294-96: “This variation might be due to the socio-economic status of the participants, access to a health facility, and sample size compared to this study.”--- This effective sample size of EBF is 103. This small sample size is incapable to capture variation socio-economic status and access to a health facility. So, emphasize the small sample size as only limiting factor and discard socio-conomic status and access to the health facility.

Response – Thank you so much for your comments. We have corrected it.

4. Line 298-302: By definition of EBF is considered 24 hours before interview. How these facility level speculations are linked with EBF within last 24 hours?

Response – Thank you so much for your comments. We have corrected it.

5. Line 296-308: The factor determination of EBF is seriously flawed by the small sample size. So, extended discussion and stronger recommendation is not applicable. For EBF, I only prefer mentioning the result and telling the consistency of literature in similar settings. IF inconsistent findings found then tell about the small sample size as a probable reason.

Response – Thank you so much for your comments. We have corrected it.

6. Line 343-45: Recommendation of further research need to add with the higher sample size (especially for the narrower age range) with other applicable robust designs.

Response – Thank you so much for your comments. We have corrected it.

7. Line 346-47: “In this study, only six indicators were used to assess the feeding practices of children.”--- Is there any more WHO indicators to assess the IYCF? Mention about the independent variables that you missed in the questionnaire.

Response – Thank you so much for your comments. We have corrected it.

Conclusion

1. Line 362-64: “We also need to address the service quality and utilization of maternal health services which is considered to be an important determinant of child feeding practices.”--- In this study service quality is not measured.

Response – Thank you so much for your comments. We have removed the sentence on service quality.

Submitted filename: Response to Reviewers 06.11.21.docx

Click here for additional data file.

1 Dec 2021

Infant and young child feeding practices and its associated factors among mothers of under two years children in a western hilly region of Nepal

PONE-D-21-02451R3

Dear Dr. Pradhan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Reviewers' comments:

6 Dec 2021

PONE-D-21-02451R3

Infant and young child feeding practices and its associated factors among mothers of under two years children in a western hilly region of Nepal

Dear Dr. Pradhan:

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PLOS ONE