Complementary feeding practices for infants and young

children in South Asia. A review of evidence for action

post-2015.
Running title: Complementary Feeding in South Asia

Manuscript (words): 4,098

Abstract (words): 249
Number of references: 36
Number of tables: 3
Number of figures: 3

This is the author manuscript accepted for publication and has undergone full peer review but
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may lead to differences between this version and the Version of Record. Please cite this article
as doi: 10.1111/mcn.12439

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Abstract

Some 37% (~64 million) South Asian children under five are stunted. Most stunting occurs

during the complementary feeding period (6-23 months). Our objective is to: 1) characterize

complementary feeding practices in South Asia; and 2) review the effectiveness of

information, education and counselling (IEC) interventions aiming to improve

complementary feeding in South Asia. We conducted a comprehensive review of: a) the latest

nationally-representative survey data; and 2) peer-reviewed interventions (Jan 1990- Dec

2015) that used IEC as the main strategy to improve complementary feeding. The analytical

sample included 30,966 children aged 6-23 months. Foods made from grains are the main

complementary food - 76.8% of children - while only 33.2% are fed fruits and vegetables rich

in vitamin A and a mere 17.1% are fed complementary foods containing meat, fish, poultry

and/or eggs. Timely introduction, minimum meal frequency, minimum dietary diversity, and

minimum acceptable diet were estimated at 57.4%, 47.7%, 33.0%, and 20.5% respectively.

The evidence on the effectiveness of IEC interventions is limited in quantity, quality and

scale. The 12 intervention studies that met the inclusion criteria indicate that IEC

interventions delivered by many types of primary care workers/community resource persons

using multiple contact opportunities improved the timeliness, frequency, diversity, and/or

adequacy of complementary feeding. However, acceptability, availability, and affordability

seem to constrain improvements in diet diversity, particularly foods of animal origin. The

small size of most intervention studies and the training/supervision intensity of counsellors,

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3
raise concerns about the potential for scale/sustainability of some of the interventions

Key words: Complementary Feeding, Infants and Young Children, South Asia.

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reviewed.
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Background

The linear growth of healthy children from birth to five years of age is remarkably similar the

world over (Multi Centre Growth Reference Study Group 2006). Yet, recent global estimates

indicate that 24% of children aged 0-59 months (i.e. 156 million) have stunted growth due to

chronic nutrition deprivation (UNICEF, WHO, WBG 2016). It is estimated that stunting - a

height-for-age z-score (HAZ) below -2 of the median in the World Health Organization

(WHO) Child Growth Standards - is the cause of about one million child deaths annually

(Black et al. 2013). For the children who survive, stunting causes lasting damage, including

poor cognition and educational performance in childhood, reduced productivity and earnings

in adulthood and, if accompanied by excessive weight gain in later childhood, increased risk

of chronic diseases (Victora et al. 2008; Dewey & Begun 2011; Black et al. 2013; de Onis &

Branca 2016).

Globally, it is acknowledged that most stunting in low- and middle-income income countries

happens during the one-thousand day period that encompasses pregnancy and the child’s first

two years after birth (Dewey & Vitta 20143). Considerable growth faltering occurs during the

prenatal period and the first six months of life and additional linear growth faltering still

happens after the first two years of life (Leroy et al. 2014). However evidence shows that the

largest proportion of stunting in low- and middle-income countries occurs during the

complementary feeding period (6-23 months), the ~500 day transition time from exclusive

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breastfeeding to consuming a wide range of family foods while breastfeeding continues

(WHO 1998).

During the complementary feeding period, children consume small amounts of foods, given

their small gastric capacity. Consequently, complementary foods need to have high nutrient

density (i.e. the amount of each nutrient per 100 kcal of food) and be fed frequently to

support optimal physical growth and brain development. Meeting the nutritional needs of

children 6-23 months old can be challenging, particularly, but not exclusively, in resource

poor settings, and can lead to stunted growth and development in infancy and early childhood

(Dewey 2016). Therefore, ensuring adequate complementary foods and feeding for children

6-23 months old is critical to achieve the global target of reducing by 40% the number of

stunted under-fives - from about 171 million in 2010 to about 100 million - by 2025 (WHO

2012).

South Asia is at the epicentre of the global child stunting crisis. The latest available data

indicate that 37% (~64 million) of South Asia’s children aged 0-59 months are stunted.

Levels of child stunting in South Asia are comparable to those in sub-Saharan Africa (36%),

twice higher than those in the Middle-East and Northern-Africa (18%) and three times higher

than those in East Asia and the Pacific (12%) or Latin America (10%) (UNICEF 2015). The

high prevalence of stunting and the region’s large child population (~26% of the world's

children under five) means that South Asia bears ~40% of the global burden of child stunting

(UNICEF South Asia 2015). Recent analyses indicate that children’s poor diets in the first

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years of life are a main driver of child stunting in South Asia (Smith & Haddad 2014; Corsi et

al. 2015); Aguayo et al. 2016). Thus, researchers and practitioners have not hesitated to refer

to the situation of complementary feeding in South Asia as a crisis (Menon 2012).

The availability of recent survey and research data documenting complementary feeding

practices in infants and young children aged 0-23 months, the availability of internationally-

agreed upon indicators to assess the adequacy of complementary feeding practices for

children 6-23 months old (WHO 2008 Part I; WHO 2008 Part II; Daelmans et al. 2009), and

the global drive to reduce child stunting as part of the post-2015 global development agenda

(WHO 2015), make it possible and necessary to take stoke of complementary feeding

practices in South Asia.

The objective of this paper is two-fold: 1) to characterize current complementary feeding

practices for infants and young children 6-23 months old in South Asia; 2) to review the

evidence-base on the effectiveness of information, education and counselling (IEC)

interventions aiming to improve complementary feeding practices in children 6-23 months

old in South Asia. Using the results from these two objectives, we then identify advocacy,

policy, programme, and research priorities to protect, promote and support optimal

complementary feeding in South Asia post-2015.

Methods

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For the purpose of this analysis, South Asia includes the eight countries under the umbrella of

the South Asia Association for Regional Cooperation (SAARC): Afghanistan, Bangladesh,

Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. To meet the objectives of the

analysis, we conducted a comprehensive review of two sources of data and information:

1) The latest nationally representative nutrition survey in Afghanistan, Bangladesh, Bhutan,

India, Maldives, Nepal, Pakistan, and Sri Lanka. For each country, we included in the

analysis the latest nutrition survey published before December 31, 2015 that met the

following criteria: a) a well-defined population-based sampling frame; b) a probabilistic

sampling procedure; c) a national-level representative sample; and d) use of internationally-

agreed upon measurements and indicators to assess feeding practices in children aged 6-23

months. The surveys included in the review are: Afghanistan, National Nutrition Survey

(NNS) 2013; Bangladesh: Demographic and Health Survey (DHS) 2011; Bhutan: NNS 2015;

India: National Family and Health Survey (NFHS) 2006; Maldives: DHS 2009; Nepal: DHS

2011; Pakistan: DHS 2013; and Sri Lanka: DHS 2007.

2) All peer-reviewed IEC intervention studies on complementary feeding for infants and

young children published between January 1990 and December 2015 for the eight South

Asian countries included in our review. Research articles were identified through on-line

search using PubMed (National Academy of Medicine and National Institutes of Health). We

used as search term <complementary feeding> combined with <Afghanistan>,

<Bangladesh>, <Bhutan>, <India>, <Maldives>, <Nepal>, <Pakistan>, <Sri Lanka> and

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<Asia> and we applied the following search filters: language <English>; text availability

<abstract>; species < human>; age range: <0-23 months>; search fields: <title/abstract>. We

only included IEC intervention studies that reported changes in complementary feeding

practices as an outcome. We did not included IEC intervention studies on complementary

feeding that focused on other outcomes (anthropometry, morbidity, or early childhood

development for example) but did not report changes in complementary feeding practices.

Similarly, we did not include studies that focused on the provision of single/multiple

micro/macro nutrient supplementation with or without IEC.

Findings

This section is organized as follows. Firstly we review the most recent national household

surveys in South Asian countries to characterize current complementary feeding practices for

infants and young children aged 6-23 months. Secondly, we review all relevant IEC

intervention studies (1990-2015) to document the effectiveness of IEC interventions aiming

to improve complementary feeding practices in children 6-23 months old in South Asia.

1. Complementary feeding of infants and young children 6-23 months old in South Asia.

The combined analytical sample included 30,966 children 6-23 months old with data on

breastfeeding and complementary feeding practices. Our analysis indicates that most (87.5%)

children 6-23 months old are breastfed. Breastfeeding rates in this age group are ≥ 75% in

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Bangladesh, India, Maldives, Nepal, Pakistan and Sri Lanka while they are ~60% in

Afghanistan. Similarly, most children 6-23 months old (85.7%) are fed soft, semi-solid or

solid complementary foods. Complementary feeding rates in this age group are ≥ 85% in all

countries (Table 1; Figure 1).

Foods made from grains are the main complementary food as an estimated 76.8% of children

aged 6-23 months are fed cereal-based complementary foods (range from 72.2% in Pakistan

to 96.2% in the Maldives). The proportion of children who are fed any of the other food

groups is below 50%. Only one child in three (33.2%) is fed fruits and vegetables rich in

vitamin A (range from 19.3% in Pakistan to 79.7% in Sri Lanka) and fewer than one child in

five (17.1%) is fed complementary foods containing meat, fish, poultry and/or eggs (range

11.2% in India to 67.8% in Sri Lanka). Consumption of complementary foods containing

pulses/nuts is a low 14% (range from 6% in Bangladesh and Pakistan to 58.3% in Sri Lanka)

and so is the consumption of dairy products (11.2%; range from 6.6% in Bangladesh to

41.8% in the Maldives). An estimated 14.9% of children 6-23 months old are fed fortified

complementary foods (range from 5.3% in Bangladesh to 51.9% in the Maldives) while 9.6%

are fed infant formula (range from 2.2% in Nepal to 47.5% in the Maldives and 53.6% in Sri

Lanka) (Table 1; Figure 1).

We assessed complementary feeding practices in children aged 6-23 months using 7 globally-

accepted indicators for assessing complementary feeding practices (WHO 2008 Part I; WHO

2008 Part II) (Table 2; Figures 2-3).

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 Continued breastfeeding at 1 year. We estimate that 88.1% of children aged 6-23

months continue to be breastfed at 1 year of age. The proportion of infants aged 12-15

months who were fed breastmilk the day prior to the survey ranges from 63.2% in

Afghanistan to 95.0% in Bangladesh. This proportion is ≥ 3/4 in all countries except

Afghanistan.

 Continued breastfeeding at 2 years. We estimate that 73.1% of children 6-23 months

old continue to breastfeed at 2 years of age. The proportion of infants aged 20-23 months

who were fed breastmilk the day prior to the survey ranges from 38.18% in Afghanistan

to 92.6% in Nepal. This proportion is ≥ 2/3 in all countries except Afghanistan, Bhutan

and Pakistan.

 Introduction of solid, semi-solid or soft foods. We estimate that 57.4% of children 6-23

months old are fed soft, semi-solid or solid complementary foods in a timely manner. The

proportion of infants 6-8 months who were fed soft, semi-solid or solid foods on the day

prior to the survey ranges from 41.3% in Afghanistan to 86.6% in Sri Lanka. This

proportion is ≥ 2/3 only in 4 countries: Bhutan, Maldives, Nepal, and Sri Lanka.

 Minimum meal frequency. We estimate that 47.7% of children 6-23 months old are fed

with a minimum frequency. The proportion of children 6-23 months of age who were fed

soft, semi-solid or solid foods the minimum number of times or more during the day prior

10

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to the survey ranges from 41.5% in India to 86.9% in Sri Lanka. This proportion is ≥ 2/3

only in 4 countries: Bhutan, Maldives, Nepal and Sri Lanka.

 Minimum dietary diversity. We estimate that 33.0% of children 6-23 months old are fed

diets that meet a minimum diversity. The proportion of children 6-23 months of age who

were fed foods from 4 or more food groups during the day prior to the survey ranges from

15.3% in Bhutan to 88.0% in Sri Lanka. This proportion is ≥ 50% only in two countries:

Maldives and Sri Lanka.

 Minimum acceptable diet. We estimate that 20.5% of children 6-23 months old are fed

diets that meet a minimum adequacy. The proportion of children 6-23 months of age who

were fed a minimum number of times and a minimum number of food groups on the day

prior to the survey ranges from 11.7% in Bhutan to 80.9% in Sri Lanka. This proportion

is ≥ 50% only in two countries: Maldives and Sri Lanka.

 Consumption of iron rich foods. We estimate that 19.4% of children 6-23 months old

are fed iron rich-foods. The proportion of children 6-23 months of age who were fed iron-

rich foods during the day prior to the survey ranges from 11.2% in India to 67.8% in Sri

Lanka. This proportion is ≥ 50% only in three countries: Bangladesh, Maldives and Sri

Lanka.

11

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2. Effectiveness of IEC interventions aiming to improve complementary feeding of children

aged 6-23 months in South Asia.

The data-base search identified 81 publications with one or more of the search terms in the

title and/or abstract. Studies were implemented in 6 of the 8 South Asian countries:

Afghanistan (1), Bangladesh (21), India (29), Nepal (6), Pakistan (9), and Sri Lanka (3). In-

depth scrutiny of the titles of these 81 publications excluded 25 publications as not relevant to

our review, identifying 56 publications as potentially relevant. In-depth scrutiny of the

abstracts of these 56 publications excluded 43 as not relevant to our review and identified 13

as likely relevant to our review. Full text scrutiny of the 13 publications excluded 1 as not

relevant and identified 12 as relevant to our review. Two publications (Bhandari et al. 2004;

Bhandari et al. 2005) referred to the same IEC intervention study while one publication

(Kimmons et al. 2004) reported findings of two IEC interventions. Thus a total of 12

publications and 12 intervention studies were included in the review (Table 3).

Six of the 12 intervention studies that met the inclusion criteria of our review were conducted

in Bangladesh, 5 in India and 1 in Pakistan. Ten intervention studies were implemented in

rural areas, 1 in an urban setting, and 1 both in rural and urban areas. All studies included

infants and young children 0-23 months old or subsets of this age group. Six studies focused

on children in the age group 0-23 months; five studies focused on children aged 6-11 months;

and one study focused on children 12-23 months old. The number of mother-child pairs

included in the studies ranged from 30 to 1025 in 11 of the 12 studies. Only one study

12

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(Kushwaha KP et al, 2014) included a larger number of mother-child pairs (n=105,000).

Studies included a variety of designs and methodologies. Six studies included a randomized

design either at the individual or cluster levels, two had a non-randomized design but

included a comparison group, and four had a non-randomized design and did not included a

comparison group (i.e. before-after comparison).

IEC services were delivered by different types of providers, including peer educators, mother

support groups, trained village women, trained project counsellors, traditional births

attendants, village-based workers, primary care physicians, community health workers,

community counsellors, India’s Auxiliary Nurse-Midwives and Anganwadi Workers, and

Pakistan’s Lady Health Visitors among others.

Only two studies reported the impact of the IEC intervention on the timely introduction of

complementary foods. Both intervention studies reported improvements in timely initiation of

complementary feeding in infants although none of the intervention studies included a

comparison group (Collison et al. 2015; Kushwaha et al. 2015). Similarly, only two studies

reported the impact of IEC interventions on feeding quantity, documenting a positive effect

of the IEC interventions on the quantity of complementary foods that children were fed per

meal: the average amount of complementary food consumed per meal increased in all age

groups (Collison et al. 2015) and mothers increased the amount they fed their infants at a

meal and the amount of time they spent feeding their children at that meal (Kimmons et al.

2004).

13

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Seven studies reported the impact of the IEC intervention on feeding frequency. Five studies

reported that the proportion of children consuming the recommended number of meals per

day increased in all age groups (Collison et al. 2015), that meal frequency was higher in the

intervention communities at 9 and 18 months (Bhandari et al. 2004), that infants in the

intervention group were more likely to be fed solids at least four times a day in addition to

breastmilk (78% vs. 51%) (Kilaru et al. 2005), and that at end-line, the frequency of

complementary feeding was significantly higher in the intervention group than in the control

group (from 30.4% to 83.8% in the intervention group vs 31% to 19.4% in the control group)

(Roy et al. 2007). In some instances, increases in feeding frequency were achieved after a

short period of intervention. For example Kimmons and colleagues report that daily meal

frequency increased from 2.2 +/- 1.3 on day 1 to 4.1 +/- 1.3 on day 7 (p<0.05) (Kimmons et

al. 2004; frequency trial). Only one study reported that the average meal frequency did not

change significantly over the study period (Kimmons et al. 2004; quantity trial).

Seven studies reported the impact of the IEC intervention on diet diversity. The seven studies

report improvements in children’s average diet diversity scores in the intervention groups:

children in the intervention groups were more likely to be fed a more diverse diet (42% vs.

19%) (Kilaru et al. 2005) and IEC interventions contributed to improve the consumption of

fruits and vegetables (Aboud et al. 2008) or cereal/legume and milk/cereal gruels or mixes

(Bhandari et al. 2004). IEC interventions also contributed to increase the consumption of

complementary foods from animal sources (eggs, liver, poultry, meat and/or fish) (Brown et

14

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al 1992; Collison et al. 2015; Vazir et al. 2013). Zaman et al. (2008) report that 180 days

after the counselling sessions, mothers in the intervention group were more likely than

mothers in the comparison group to report to offer eggs (47.6% vs. 26.7%) or

chicken/beef/mutton (60.3% vs. 39.7%) to their children (p≤0.05). However, despite

improvements following the IEC intervention, children’s consumption of milk and foods of

animal origin was low (Bhandari et al. 2004). Vazir et al. (2013) report that foods of animal

origin and/or eggs were fed to less than 30% to 50% of children across groups respectively.

Finally, some studies report that the IEC interventions improved responsive feeding (Aboud

et al. 2008; Aboud et al. 2009) and reduced gender differentials in feeding between girls and

boys (Kilaru et al. 2005).

Discussion

We reviewed the survey and research evidence available to characterize current

complementary feeding practices for children 6-23 months old in South Asia and to review

the effectiveness of IEC interventions aiming to improve complementary feeding in this age

group.

We find that complementary feeding practices in South Asia are far from optimal. Less than

three in five infants (57.4%) aged 6-8 months are fed soft, semi-solid or solid foods,

indicating late initiation of complementary feeding. Furthermore, less than half of children

aged 6-23 months are fed with a minimum frequency per day and only about one-third are fed

15

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diets that meet a minimum diversity. Complementary foods for children aged 6-23 months

are primarily cereal-based diets lacking, for a vast majority of South Asian children, the

essential growth-promoting nutrients provided by fruits and vegetables (only 1 in 3 children

6-23 months old are fed fruits and vegetables) and foods of animal origin (less than 1 in 5

children are fed meat, fish, poultry, and/or eggs).

These regional estimates are driven by the poor indicators of complementary feeding in

Afghanistan, Bangladesh, India, Nepal and Pakistan, the 5 highest population countries in the

region, which also happen to be the countries with the largest proportion and number of

stunted children in South Asia. Sri Lanka and Maldives stand out as outliers as indicated by

children’s higher consumption of fruits, vegetables, pulses, dairy, and foods of animal origin.

In Sri Lanka all indicators of complementary feeding – timeliness, minimum frequency,

minimum diversity and minimum adequacy - are above 80%, indicating that South Asian

countries can be high performers on complementary feeding.

Our review of the potential effectiveness of information, education and counselling (IEC)

interventions to improve complementary feeding practices in South Asia is limited by the low

number of intervention studies (n=12), their emphasis on Bangladesh and India (11 of the 12

studies), their primary focus on rural areas (10 of the 12 studies), and the variety of outcomes

that assessed and methodologies used. With these caveats in mind, the interventions studies

we reviewed indicate that IEC delivered by peer educators, mothers support groups, trained

counsellors, community health workers, and primary health care staff and others were able to

16

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improve the timeliness, frequency, diversity and minimum adequacy of complementary

feeding in children.

Authors highlight the importance of good practical skills on counselling and supervision,

frequent counselling contacts, incentives for counsellors, and a supportive health system

(Kushwaha et al. 2014). Frontline workers trained on counselling skills, are more likely to

discuss with mothers the foods that are more appropriate for the age of the child, and check if

the mothers have understood the information provided (Zaman et al. 2008). To achieve high

coverage and wide adoption of recommended practices, many types of primary care workers

and counselling at multiple opportunities seem essential (Bhandari et al. 2004). There is also

evidence that using multiple and existing workers and opportunities for counselling

caregivers is feasible, can result in high coverage and impact, and instead of disrupting

ongoing services, can improve them (Bhandari et al. 2005).

Although intervention studies indicate that IEC interventions can improve the consumption of

micronutrient rich foods, social norms and time and/or financial resources may constraint the

impact of IEC interventions. Mothers and caregivers may find counter to normative infant

feeding beliefs that children aged 9 to 11 months need to be fed complementary foods of

animal origin (Vazir et al. 2013). In addition, availability and affordability of such foods can

also be a constraint to optimal complementary feeding. Mothers may be reluctant to feed

young children foods of animal origin because of cost and, as may tend to implement the IEC

17

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advice/messages that require little time and/or money and avoid to implement those that

require more preparation time and/or are more expensive (Brown et al. 1992).

In summary, complementary feeding practices in South Asian children are characterized by

late introduction of complementary foods, insufficient feeding frequency, and poor diet

diversity. As a result, only 20% of children are fed diets that meet minimum levels of

adequacy for appropriate child growth and development. This is of great concern given the

high levels of child stunting in South Asia. Recent studies show that better complementary

feeding practices predict better linear growth outcomes in South Asian children. In rural

Bangladesh, children who were fed a minimum acceptable diet at 9 months had better height-

for-age outcomes and were less likely to be stunted at age 24 months (Owais et al. 2016). In

Nepal, minimum meal frequency and minimum diet diversity were positively associated with

height-for-age in children 6-23 months. The combination of minimum meal frequency and

minimum diet diversity had the greatest effect on indicators of child growth (Crum et al.

2013). In India, poor dietary diversity was an important predictor of stunted growth in

children (Corsi et al. 2015). For example, in Maharashtra, children 6-23 months old whose

diets did not include eggs had a two-fold higher risk of being stunted (Aguayo et al. 2016). In

Bhutan, children aged 6-23 months who were not fed complementary foods at 6–8 months

had about three-fold higher odds of being severely stunted than children who were fed

complementary foods (Aguayo et al. 2015).

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The evidence on the potential effectiveness of IEC in improving complementary feeding

practices in South Asia is limited in quantity, scale and methodology. The small size of most

of the intervention studies and the intensity of the training and supervision of community

counsellors and health workers, raises concerns with respect to the potential for scale and

sustainability of some of these interventions. Recently published findings from a large-scale

intervention programme in Bangladesh indicate that the combination of more intensive

interpersonal counselling, mass media, and community mobilization (IPC+MM+CM

intensive) brought about significantly higher improvements in complementary feeding

indicators than a standard nutrition counselling + less intensive MM + CM (non-intensive)

intervention. In the intensive group, CF practices were high: 50.4% for minimum acceptable

diet, 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for

consumption of iron-rich foods. The authors conclude that large scale program delivery was

feasible and, with the use of multiple platforms, reached 1.7 million households and claim

that their study establishes proof of concept for large-scale behaviour change interventions to

improve child feeding (Menon et al. 2016).

In conclusion, complementary feeding practices in South Asia are unacceptably poor to

ensure that children can grow and develop to their full potential. The improvement of

children’s diets in the first two years of life needs to be an advocacy priority of national and

international stakeholders who are concerned by the sustainable development of South Asian

nations. Country governments need to ensure that national policies on Food and Nutrition

Security and Maternal and Child Nutrition and Health, are aligned with internationally

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agreed-upon recommendations to protect, promote and support age-appropriate

complementary foods and feeding practices for infants and young children. National

governments and their development partners need to design, implement and document

evidence-based, large scale programmes for the promotion and support of improved

complementary feeding for children aged 6-23 months. The scarcity of programme

monitoring and evaluation data in this area is of great concern. Finally, researchers need to be

supported to document the main drivers of poor complementary feeding in South Asia and –

importantly - the pathways to overcome barriers and constraints to the uptake of

recommended complementary feeding practices by caregivers and families.

20

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Key messages

 South Asia is at the epicentre of the global child stunting crisis. Some 37% (~64 million)
of South Asia’s children aged 0-59 months have stunted growth. Most stunting occurs
during the complementary feeding period (6-23 months).

 Foods made from grains are the main complementary food (76.8% of children 6-23
months) whereas only 33.2% are fed fruits and vegetables rich in vitamin A, and a mere
14% are fed complementary foods containing meat, fish, poultry and/or eggs.

 Timely introduction of complementary foods, minimum meal frequency, minimum

dietary diversity, and minimum acceptable diet in children aged 6-23 months were
estimated at 57.4%, 47.7%, 33.0%, and 20.5% respectively.

 Information, Education and Counselling (IEC) interventions delivered by primary care

workers/community resource persons using multiple contacts/opportunities improved
timeliness, frequency, diversity, and/or adequacy of complementary feeding. However,
acceptability, availability, and affordability seem to constrain improvements in diet
diversity, particularly foods of animal origin.

 The small size of most intervention studies and the training/supervision intensity of
counsellors, raise concerns about the potential for scale/sustainability of some of the
interventions reviewed.

Source of funding: United Nations Children’s Fund (UNICEF) Regional Office for South
Asia (ROSA) for data analysis, interpretation and manuscript writing.

Conflict of interest statement: The author declares that he has no conflict of interest. The
opinions expressed on this paper are those of the author and do not necessarily represent an
official position by UNICEF.

Contributor statement: VMA designed the study and conducted data analysis and
manuscript writing.

21

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Figure 1: Proportion of South Asian children 6-23 months old who are fed different foods and food groups, 2006-2013

100

90 87.5
85.7

80 76.8

70
Prevalence (%)

60

50
46.0

40
33.2
28.6
30

18.4 17.1
20 14.9 14.0
11.2 9.6
10

0
Breastmilk Any solid or Food made Other milk Fruits/ Food made Other fruits/ Meat, fish, Fortified baby Food made Cheese, yogurt, Infant formula
semi-solid food from grains vegetables rich from vegetables poultry, eggs foods from milk products
in vitamin A roots/tubers pulses/nuts

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Figure 2: Complementary feeding practices in infants and young children 6-23 months old in South Asia, 2006-2013

100 95.0
92.6
88.1 86.6 86.9 88.0
90
80.9
80
73.1
70 67.8
63.9

60 57.4
Prevalence (%)

50 47.7
41.3 41.5
40 37.8
33.0
30
20.5 19.4
20 15.3
11.7 11.2
10

0
Continued breast Continued breast Introduction of Minimum meal Minimum diet Minimum acceptable Iron rich foods
feeding at 1 year feeding at 2 years complementary foods frequency diversity diet

Highest value South Asia Lowest value

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Figure 3: Complementary feeding practices in infants and young children 6-23 months old in South Asian countries, 2006-2013

100

90 86.9 88.0
80.9
78.5
80
73.8 72.2

70 66.9
64.5
62.7
57.6
Prevalence (%)

60
52.1
50 47.7
41.5
40 35.3
33.0
28.5 27.6
30 24.4 25.2
20.9 20.7 22.2
20.5
20 14.8 15.3
12.2 11.7
10

0
Sri Lanka Maldives Nepal Bangladesh India Pakistan Afghanistan Bhutan South Asia

Minimum meal frequency Minimum diet diversity Minimum adequate diet

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Table 1. Breastfeeding and complementary feeding in children aged 6-23 months by country in South Asia

Afghanistan Bangladesh India Maldives Nepal Pakistan Sri Lanka South Asia
NNS 2013 DHS 2011 DHS 2006 DHS 2009 DHS 2011 DHS 2012 DHS 2007
Breastmilk 59.9 94.3 89.8 78.4 95.3 74.8 91.0 87.5
Other milk 24.8 48.0 67.2 43.9 49.3 50.6 46.0

Any solid or semi-solid food 87.3 84.9 97.7 92.3 87.2 96.9 85.7

Food made from grains 76.7 75.1 77.2 96.2 88.1 72.2 95.5 76.8
Fruits and vegetables rich in vitamin A 36.8 34.4 65.5 34.6 19.3 79.7 33.2
Food made from roots and tubers 51.0 41.1 22.6 20.2 65.0 41.5 56.4 28.6
Other fruits and vegetables 18.0 15.3 34.2 21.4 33.7 44.5 18.4
Meat, fish, poultry, eggs 30.8 43.5 11.2 57.0 17.3 24.9 67.8 17.1
Food made from pulses and nuts 27.1 5.9 14.4 24.0 49.1 6.0 58.3 14.0
Cheese, yogurt, other milk products 6.6 11.1 41.8 9.0 13.6 27.9 11.2

Fortified baby foods 5.3 15.8 51.9 7.9 15.3 34.6 14.9
Infant formula 6.3 10.2 47.5 2.2 5.9 53.6 9.6

NNS: National Nutrition Survey; DHS: Demographic and Health Survey

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Table 2. Indicators of complementary feeding in children aged 6-23 months by country in South Asia

BF12-15 BF20-23 CF6-8 MMF MDD MAD Fe-rich

Afghanistan (NNS 2013) 63.2 38.1 41.3 52.1 27.6 12.2 32.6
Bangladesh (DHS 2011) 95.0 89.6 62.6 64.5 25.2 20.9 53.6
Bhutan (NNS 2015) 92.0 60.0 86.9 66.9 15.3 11.7 16.6
India (DHS 2006) 89.4 74.8 56.7 41.5 35.3 20.7 11.2
Maldives (DHS 2009) 77.3 68.4 81.8 73.8 72.2 57.6 57.0
Nepal (DHS 2011) 92.5 92.6 70.4 78.5 28.5 24.4 24.1
Pakistan (DHS 2012) 80.6 56.1 56.6 62.7 22.2 14.8 34.6
Sri Lanka (DHS 2007) 92.2 83.9 86.6 86.9 88.0 80.9 67.8

South Asia 88.1 73.1 57.4 47.7 33.0 20.5 19.4

BF12-15: continued breastfeeding at one year; BF20-23: continued breastfeeding at two years; CF6-8: introduction of solid, semi-solid or soft foods;
MMF: minimum meal frequency; MDD: minimum diet diversity; MAD: minimum acceptable diet; FE-rich: consumption of iron rich foods.

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Table 3. Summary of intervention studies to improve complementary feeding practices through Information, Education, and Counselling (IEC)

Age Timely Feeding Feeding Diet Other

Study Country Setting Size Type Intervention
group introduction quantity frequency diversity outcomes

Aboud FE et Bangladesh Rural 12-23 mo 102 and 100 Cluster randomized Counselling on - Improved diet - Improved
al. Maternal mother-child field trial responsive feeding diversity (eggs, mothers'
and Child pairs in by peer-educators. fruit, vegetables). knowledge
Nutrition, intervention Intervention group - Less on responsive
2008. and 6 weekly sessions biscuits/sugar feeding:
comparison on responsive among children in percentage of
groups feeding. Control the intervention self-fed
respectively group 6 regular group. mouthfuls
weekly sessions on greater in
child nutrition. intervention
group but no
difference in
mean number
of food
mouthfuls per
child.

Collison DK et India Rural/urban 6-23 mo 30 rural and 30 User testing: Trial of 14-day TIPS trial to - Improved - Average - Proportion of - Consumption of
al. Food Nutr (Bihar) urban mother- Improved Practices test acceptability of initiation of amount children animal sources of
Bull, 2015. child pairs (TIPS) low cost and easy CF in infants consumed consuming the food (meat or eggs)
to use feeding 6-8 mo. per meal recommended increased among
toolkit (bowl, (feeding number of children 6-11 mo.
spoon, and quantity) meals per day
illustrated increased in increased in all
counselling card. all age age groups.
Counselling groups.
provided by trained
project assistants.

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Kushwaha KP India Rural 0-23 mo 105,000 Quasi experimental IYCF counselling - Initiation of
et al. PLoS (Uttar mother-child before and after study to mothers by CFeeding at
One, 2014. Pradesh) pairs over 5 years. mother support T0, T2 and
groups (MSG) T5 were 54%,
through facility- 85% and 96%
and community- respectively.
based outreach.
Members of the
MSG received a
token amount of R.
50 per month for
their services.
- Only 4 IYCF
practices. 3 of them
related to BF
(initiation,
exclusive,
continued).

Vazir S et al. India Rural 0-23 mo 600 mother- Cluster-randomized Control group (CG) - More children in
Maternal and (Andhra child pairs trial (12-mo received routine intervention groups
Child Pradesh) (200 per intervention) ICDS services. CF were fed liver,
Nutrition, comparison group received poultry, goat meat,
2013. group) ICDS + counselling egg, spinach, pulses
on WHO and added fat (at 9
recommendations and 15 mo).
on CF. Responsive - Despite
CF and play group intervention, liver,
received same as goat meat, poultry
the CFG + skills for and greens were fed
responsive feeding to < 30% of children
and psychosocial across groups and
stimulation. Both eggs and added fat
intervention groups to ~ 50%.
received bi-weekly
visits by trained
village women.

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Bhandari N et India Rural 0-23 mo 1,025 new- Cluster randomized 4 types of health - Meal - Significant
al. Health (Haryana) borns enrolled: controlled trial and nutrition frequency was improvement in
Policy and 552 workers (traditional higher in the consumption of
Planning, intervention birth attendants, intervention cereal/legume
2005. group; 473 local village-based communities at gruels or mixes,
control group. workers, auxiliary 9 and 18 milk/cereal gruels or
nurse midwives, months of age. milk/cereal mixes
and primary care and of undiluted
physicians) were milk at 9 and 18
trained to counsel months in children
mothers at multiple in the intervention
contacts on communities.
exclusive BF for - Low consumption
Bhandari N et the first 6 months of milk and foods of
al. J Nutr, and appropriate CF animal origin.
2004. thereafter. The
intervention
included
community and
health worker
mobilization.

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 17408709, 2017, S2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.12439, Wiley Online Library on [22/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Zaman S et al. Pakistan, Urban 6-23 mo 375 mother- Single-blind cluster Lady Health - Mothers in
J Health Popul (Lahore) child pairs randomized controlled Visitors (LHV) intervention group
Nutr, 2008. (129 pairs trial were trained in were 1.5-3 times
intervention nutrition more likely to recall
and 137 pairs counselling using correct advice
control) IMCI’s 'Counsel delivered during the
the mother' module. consultation.
A local adaptation - After 180 days of
of Pakistan’s IMCI consultation, the
‘feeding proportion of
counselling card’ mothers reporting to
was developed in offer eggs (47.6%
the local language vs 26.7%),
highlighting the chicken/beef/mutton
recommended (60.3% vs. 39.7%)
foods and or thick kitchuri
frequency of (65.9% vs. 44.3%)
feeding to be to their children was
discussed with significantly higher
mothers according than in the
to the age of the comparison group
child and to act a s (p≤0.05).
a reminder at home
of the
recommendations
received in the
health center.
Mother-child pairs
were visited at
home within two
weeks, 45 days, and
180 days after
recruitment

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 17408709, 2017, S2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.12439, Wiley Online Library on [22/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Brown LV et Bangladesh Rural 6-12 mo 62 mother- Community-based non- Village workers - After intervention,
al. Am J Clin breastfed randomized hired by BRAC fish/meat
Nutr, 1992. infant pairs in effectiveness trial. were trained in CF consumption in
the counselling to intervention group
intervention mothers, including (66%) was
group and 55 home significantly higher
in the demonstrations of than in comparison
comparison snack-type recipes group (13%).
group. and instruction for
enriching meals
with energy,
protein, and other
nutrients. Messages
encouraged
continued BF in
addition to frequent
and persistent
feeding of new
foods, proper food
storage, hand
washing and
washing of utensils
before cooking and
feeding.

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 17408709, 2017, S2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.12439, Wiley Online Library on [22/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kilaru A et al. India Rural 5-11 mo 138 mother- Non-randomized Monthly nutrition - Infants in the - Infants in the - Girls in the
Indian (Karnataka) infant pairs controlled trial education delivered intervention intervention group intervention
Paediatrics, (intervention (sequential by locally-trained group were were more likely to group were
2005. group n=69). intervention/comparison counsellors (hired more likely to be fed a more more likely to
groups) by the project) be fed solids at diverse diet (42% report at least
targeted at least four times vs. 19%) 4/6 positive
caregivers of a day in behaviours
infants aged 5-11 addition to than girls in
months until 23 breastmilk the non-
months of age. (78% vs. 51%). intervention
group. No
significant
differences
were
observed for
boys.

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Kimmons JE Bangladesh Rural 6-12 mo 30 mother- Prospective short-term Trial 1 (meal - Amounts - Average meal
et al. Food infant pairs behavioural change trial quantity trial): consumed frequency did
Nutr Bull, Educational on days 5 not change
2004. messages to and 7 were significantly
increase the significantly over the study
quantity of food greater than period.
offered to and the amount
consumed by consumed
infants at each on day 1,
meal. Mothers were and the
asked to feed their duration of
children more once the meals
mothers felt that the significantly
feeding session had longer on
ended. days 4 and 7
vs. day 1.
- Mean
intake from
single meals
increased
from 40 +/-
23 g on day
1 to 64 +/-
30 g on day
7 (p < 0.05).
- Mothers
increased
the amount
they fed
their infants
at a meal by
60% and
they
doubled the
amount of
time spent
feeding at
that meal.

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Trial 2 (meal Meal
frequency trial): frequency
Educational increased from
message to increase 2.2 +/- 1.3 on
the frequency of day 1 to 4.1 +/-
complementary 1.3 on day 7.
food meals. 30 - The
mothers were asked percentage of
to feed at least three mothers who
meals per day, and cited time
more if possible. A constraints to
meal was defined meal frequency
as a separate decreased from
feeding of greater 47% to 33% ,
than 10 g. The the percentage
study lasted for citing lack of
seven days. No money
food was provided decreased from
by the study team. 33% to 23%,
and the
percentage
citing lack of
food decreased
from 13% to
7%. The
percentage
who responded
that the baby
did not want to
eat more meals
than the
current level
increased from
37% to 47%.

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 17408709, 2017, S2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.12439, Wiley Online Library on [22/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Aboud FE et Bangladesh Rural 8-20 mo 108 Cluster-randomized A 6-session - Percent of
al. J Nutr, (intervention trial counselling self-fed
2009. group) and 95 program that mouthfuls
(comparison emphasized the was 47.8 ±
group) mother- practice of 42.4 in the
child pairs responsive feeding intervention
to encourage group
mothers to feed compared to
their children in 32.2 ± 41.0 in
response to the
children’s cues and comparison
psychomotor group
abilities vs. (p=0.01)
information and - Number of
counselling responsive
delivered by the verbalizations
regular nutrition was 6.55 ±
education 5.9 in the
programme. intervention
mothers and
4.62 ± 4.5 in
comparison
mothers
(p=0.01).
- Mouthfuls
of food eaten
by children
(self-fed and
mother-fed)
and weight
gain were
similar in the
2 groups.

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Roy SK et al. Bangladesh Rural 6 to 9 mo 605 normal Community-based, Nutrition and - Significant
Food and and mildly randomized, controlled stimulation increase in the
Nutrition undernourished trial. intervention vs. frequency of
Bulletin, 2007. children nutrition or complementary
stimulation only. feeding in the
Intervention group intervention
received weekly group as
nutrition education compared with
for 6 mo. The the control
control group group (from
received regular 30.4% at
BINP services. baseline to
Emphasis on 83.8% at end-
demonstrations of line vs 31% to
the preparation of 19.4%
nutrient-rich local respectively)>
complementary The increase
foods, and the was sustained
prevention, throughout the
recognition, and observation
treatment of period.
diarrhoea and acute
respiratory
infections.
Community health
workers/counsellors
delivered the
messages to small
groups of mothers
(6 to 8 mothers in
each group).

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Complementary feeding practices for infants and young
children in South Asia. A review of evidence for action
post-2015.
Víctor M. Aguayo1
1
United Nations Children’s Fund (UNICEF). Programme Division, New York, USA.

Address for correspondence: Dr. Víctor M. Aguayo, United Nations Children’s Fund
(UNICEF). 3UN Plaza, New York, NY10017. [email protected]

Running title: Complementary Feeding in South Asia

Manuscript (words): 4,098

Abstract (words): 249
Number of references: 36
Number of tables: 3
Number of figures: 3

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