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Indian Pediatr 2018;55: 284-286 |
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The Slippery Slope of Child Feeding Practices
in India
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Rajib Dasgupta, Ipsha Chaand and Kirti Rakshit Barla
From Centre of Social Medicine and Community Health,
Jawaharlal Nehru University, New Delhi, India.
Correspondence to: Dr Rajib Dasgupta, Professor,
Centre of Social Medicine and Community Health, Jawaharlal Nehru
University, New Delhi 110 067, India.
Email: [email protected]
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National Family Health Survey 4 (NFHS-4) data shows a ten percentage
point decline in timely complementary feeding rates in the backdrop of
increases in breastfeeding indicators. There is large-scale decline in
this indicator across all regions and states. An understanding of social
determinants is critical for generating transformative ideas to address
these challenges.
Keywords: Complementary feeding, Decline,
National health surveys, Social determinants.
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T he recently released National Family Health
Survey 4 (NFHS-4) data brings our focus on the decline in timely
complementary feeding rates, from 52.6% (2005-06) to 42.7% (2015-16), in
the backdrop of increase in exclusive breastfeeding (46.4% (NFHS-3) to
54.9% (NFHS-4)), and decrease in underweight and stunting levels [1]. We
unpack some of the nuances of data related to Infant and Young Child
Feeding (IYCF) and highlight key social determinants of the problem.
This assumes relevance in the context of the significance of ‘critical
window of opportunity’ for prevention of growth faltering and improving
nutritional status of under-five children.
Key IYCF Indicators from NFHS-4
The NFHS-4 reported that merely 9.6% children aged
6-23 months receive an adequate diet; this includes 14.3% of
non-breastfeeding children and 8.7% of breastfeeding children; urban
indicators are better in most cases by a few percentage points. There is
no comparable data for these indicators in the previous round.
Comparison is possible for another indicator: children (6-8 months)
receiving solid or semi-solid food and breast milk (Table I).
TABLE I Changes in IYCF Indicators from NFHS-3 to NFHS-4 (Selected States)
|
|
Children receiving
solid or semi-solid food
and breast milk (%) |
|
|
States |
Trend
|
|
|
(%) |
|
|
|
|
|
NFHS-3
(2005-2006) |
NFHS-4
(2015-2016) |
|
India |
|
52.6 |
42.7 |
-9.9 |
North |
Rajasthan |
38.7 |
30.1 |
-8.6 |
|
Punjab |
50.9 |
41.1 |
-9.8 |
|
Uttar Pradesh |
41.2 |
32.6 |
-8.6 |
North-East |
Sikkim |
85.4 |
61.8 |
-23.6 |
|
Manipur |
77.4 |
78.38 |
1.4 |
|
Arunachal Pradesh |
80.2 |
53.6 |
-26.6 |
West |
Gujarat
|
54.1 |
49.4 |
-4.7 |
|
Maharashtra |
45.5 |
43.3 |
-2.2 |
Central |
Madhya Pradesh |
46 |
38.1 |
-7.9 |
|
Chhattisgarh |
49 |
53.8 |
4.8 |
East |
Bihar |
54.5 |
30.7 |
-23.8 |
|
Jharkhand |
60.2 |
47.2 |
-13 |
|
West Bengal |
47.1 |
52 |
4.9 |
|
Odisha |
65.4 |
54.9 |
-10.5 |
South |
Karnataka |
69.7 |
46 |
-23.7 |
|
Tamil Nadu |
81.2 |
67.5 |
-13.7 |
|
Kerala |
93.9 |
63.1 |
-30.8 |
Source: International Institute of Population Sciences
(IIPS). National Family Health Survey, India: Key Findings from
NFHS-4 (2015-16); IYCF: Infant and young child feeding; NFHS:
National family health survey. |
There is large scale decline in this indicator across
all regions and states, barring a few exceptions (Manipur, Nagaland,
Chhattisgarh and West Bengal). In 12 states (Haryana, Sikkim, Meghalaya,
Assam, Mizoram, Arunachal Pradesh, Bihar, Jharkhand, Odisha, Karnataka,
Tamil Nadu and Kerala), the decline is below the national average. Among
the Empowered Action Group (EAG) or high focus states, Bihar (23.8%),
Jharkhand (13%), Odisha (10.5%) and Assam (10.2%) reported the maximum
declines. Notably, the largest declines were reported from the Southern
states (ranging from 13% to 30% in Karnataka, Tamil Nadu and Kerala).
State level indicators in the current round point
towards low rates of optimal child feeding practices, both in states
that have witnessed some of the largest declines as well as some of
those with improvements, with the exception of Tamil Nadu and Kerala
that have higher rates despite an overall decline (Table II).
TABLE II Child Feeding Practices in Key States (NFHS-4)
|
Total children age |
Children age 6-8 mo
|
Breastfeeding children |
Non-breastfeeding children
|
|
6-23 mo receiving
|
receiving solid or semi-
|
age 6-23 mo receiving |
age 6-23 mo receiving an |
|
an adequate diet (%) |
solid food and breast |
an adequate diet (%) |
adequate diet (%) |
|
|
milk (%) |
|
|
India |
9.6 |
42.7 |
8.7 |
14.3 |
Bihar |
7.5 |
30.7 |
7.3 |
9.2 |
Jharkhand
|
7.2 |
47.2 |
7.2 |
7.1 |
Madhya Pradesh |
6.6 |
38.1 |
6.9 |
4.8 |
Chhattisgarh |
10.9 |
53.8 |
11.1 |
8.4 |
Odisha |
8.5 |
54.9 |
8.9 |
5.0 |
Rajasthan |
3.4 |
30.1 |
3.4 |
3.7 |
Assam |
8.9 |
49.9 |
8.7 |
10.8 |
Uttar Pradesh |
5.3 |
32.6 |
5.3 |
5.3 |
Karnataka |
8.2 |
46.0 |
5.8 |
14.4 |
Kerala |
21.4 |
63.1 |
21.3 |
22.3 |
Tamil Nadu |
30.7 |
67.5 |
21.4 |
47.1 |
Maharashtra |
6.5 |
43.3 |
5.3 |
12.2 |
Gujarat |
5.2 |
49.4 |
5.8 |
2.8 |
Source: International Institute of Population Sciences
(IIPS). National Family Health Survey, India: Key Findings from
NFHS-4 (2015-16). |
Unraveling the Social Determinants
IYCF is influenced by multiple factors: early
initiation, delay or inadequacy (consistency, number of feeds and
quantity), practice of the popular notion of ‘feeding on demand’,
autonomy of decision-making, poor control over time spent on care and
feeding, knowledge gap of mother/caregiver on complementary feeding, and
the need to resume work by mother. Mothers’ engagement in household
chores, livelihood and responsibility of children leave them with little
time and choice to cook and prepare age-appropriate complementary foods
[2]. Mothers engaged in income generation face greater difficulty in
infant and young child feeding while caregivers (siblings, elders or
neighbors) are unable to serve as an adequate alternative for care. In
absence of support for child care at workplace or an alternative for
child care, mothers find it difficult to practice exclusive
breastfeeding or timely complementary feeding [2]. Early initiation of
complementary feeding is reported among low birthweight and preterm
infants [3]. Children are thus often initiated complementary feeding
before 6 months of age, and with food that is low in nutrition and
diversity but high in calories (packaged/convenience foods). Children
are primarily looked after by the caregivers who feed children ‘whenever
the child is hungry’ or ‘whenever the child asks for food’ [3].
It is amply evident from Table II that
states with high levels of chronic poverty and repeated cycles of male
migration have poor IYCF indicators. In households with multiple
migration cycles, left-behind (a new and unique vulnerability that is
gaining recognition) children face the consequences of early initiation
– inadequacy as well as low quality of complementary feeding [4]. The
growing number of male migrants and episodes/cycle of migration has led
to feminization of agriculture and waged labor, with consequent
challenges for childcare and feeding (worse in households where children
are left in the care of elder siblings). Over-burdened women get little
time for food-gathering (green vegetables, fruits or tubers from
commons) or cooking food separately for children, who end up eating
diets meant for adults (with little diversity) [5,6].
No Magic Bullets
Anganwadi Workers (AWWs) and Accredited Social Health
Activists (ASHAs) are the frontline workers trained to promote IYCF and
counsel caregivers of children. The emphasis during training and the
knowledge and focus of the workers is disproportionately on
breastfeeding than age-appropriate complementary feeding [7]. This
imbalance is partly the product of the promotion of breastfeeding that
has its roots in the Child Survival and Development Revolution (CSDR)
since 1982, followed by later initiatives including the Baby Friendly
Hospital Initiative by the WHO and UNICEF –that to a significant extent
was shaped by HIV/AIDS concerns. But it also goes deeper than that.
Nutrition counseling provided by ASHAs was also reported to be low in
some of the key states and their knowledge on complementary feeding was
poor [8]. While the ASHA is incentivized for home visits during which
she has to counsel and promote complementary feeding, there are no
robust monitoring mechanisms or supportive supervision.
Issues of child feeding and its bearing on nutrition
may contribute to our understanding on the rising epidemic of ‘metabisity’
in a life-course perspective. Recent analyses suggest that roles of
government, technical agencies, funders, civil society, media and the
industry range from being supportive to the issue of IYCF (at best), and
unsupportive, or even antagonistic and confrontational (at worst) [9].
On the other hand, there is scant policy attention to inequalities that
women face as producers, consumers, and home food managers [10].
Healthworker-based interventions and advocacy for behavioral change,
including through the Integrated Child Development Services (ICDS), have
made limited impact in rapidly transitioning societies (where men and
women make profound adjustments to preferences, ideas and beliefs with
consequences for health). The lack of maternity protection and support
mandates are nested within larger food insecure environments (chronic,
transitory or cycles) that need to be recognized as entitlement failures
and addressed urgently in a social justice framework. Transformative
ideas are needed that must entail posing critical questions,
interpretation and expository writing as well as skill development to
enable translating slogans to skills.
Contributors: RD: conceptualized the write-up;
IC, KRB: contributed to the review and data analysis. All three authors
contributed to preparation of the manuscript and approved the final
version.
Funding: None; Competing interests:
None stated.
References
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%20Training%20to%20Assess%20the%20Skills%20and
%20Knowledge%20of%20Frontline%20providers%20. pdf. Accessed August
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