CHALLENGES OF INFANT AND YOUNG CHILD FEEDING IN SUB SAHARAN AFRICA

Corresponding Author: A Laving

Africa is surprisingly the fastest growing continent on the planet despite its tribulations of poverty, civil wars, drought, famine and the devastating impact of HIV and AIDS. This is largely due to the high fertility rates in the Sub Saharan region where population is expected to double by mid century as estimated by the The United Nations World Population Prospects (1).Despite the large numbers of children born in Africa, their survival rate is crippled by the inadequate neonatal services, risk of infection from communicable diseases and compounding impact of malnutrition. While under five mortality has decreased significantly across the world current data shows that it remains highest in Sub Saharan Africa which accounts for almost half of all under five mortalities with a rate of 98/1000 live births. Various interventions have been introduced in an attempt to meet the millennium development goal of decreasing under five mortality by two thirds by the year 2015. A key invention point isto decrease malnutrition which associated with 45% of deaths in this age group as reported by the United Nations Interagency Group for Child Mortality Estimation in the 2013 report(2).In Kenya 35%, 7% and 4% of children under five were found to be stunted, wasted and underweight respectively as per 2008-2009 National Health Survey(3).

A number of factors have been identified as barriers to appropriate Infant and Young Child Feeding which recommends initiation of breast feeding within one hour of delivery, exclusive breast feeding for the first 6 months of life followed by the introduction of appropriate complementary foods and continuation of breast feeding until 2 years of age and beyond.This ambitious but difficult to implement strategy was endorsed by the World Health Assembly in May 2002.

The Kenyan Ministry of Health conducted a qualitative assessment into the beliefs and attitudes surrounding infant and young child feeding in various regions of the country. Administration of prelacteal feeds was found to be a method of cleansing the stomach in preparation for breast feeding and the feeds introduced tended to vary with regional distribution though warm water was commonly used. Forty four percent of neonates receive prelacteal feeds in Kenya and the practice is more common in households with low income and rural mothers. Worryingly, among 46%ofGiriama of Kenya and 34% of mothers in Igunga/ Mbulu regions of Tanzania, the highly nutritious colostrum milk was regarded as dirty and discarded only for child to receive less nutritious prelacteal feeds such as glucose water. (4,5) Only one in three Kenyan children is exclusively breast fed for the recommended 6 months with similar results in neighbouring Tanzania. Only two in three of Kenyan children are still breast feeding by the age of 23 months. Against standing regulations and policies 60 % of infants are on weaning foods by age 4 – 5 months. Ground cereal grains are the most common weaning foods and are introduced as early as 3 months in one third of Kenyan infants with similar findings in Malawi. (6)

Webb–Girard et al identified food insecurityas a factor that negatively impacts on EBF as mothers perceive that their milk is inadequate in both quantity and quality.(7) Mothers with enough to eat are regarded as being able to provide enough milk for their children. Maternal hunger,workload and family demands are barriers to EBF andwith womenincreasingly working away from home, the pressure to introduce weaning foods early is insurmountable. Cultural beliefs do not favor EBF as a crying child is perceived to be hungry and this further increases the pressure to introduce other feeds to the baby. In Loitokitok Kenya, early weaning is regarded as a sign of caring for the baby and leads to social acceptance. Young mothers regard their own mothers and mothers in-law as a key source of information on how to feed their childrenand tend to receive the wrong advice. (4)

When asked about how they feed their children, Kenyan mothers cited social and economic factors as the most influential for infant and young child feeding practices. Social factors included peer pressure to introduce foods early and lack of support from the community for optimal infant and young child feeding practices. Other social factors were age of the mother, marital abuse and stress. Younger mothers looked to older mothers for guidance, but often the older women had incorrect information. Economic factors included lack of money to buy appropriate food leading to food insecurity, as a result of high unemployment rates and poverty levels. There was a general belief that if the mother’s diet was insufficient, the breast-milk would
be inadequate. Surprisingly, mothers did not report cultural and religious factors as being significant in the way they fed their children.(4)

Appropriate child feeding practices and parental behavior have been shown to have a positive impact of infants and young children’s growth(8 ). Wondafrash and others in a study of caregivers of children aged 6 to 23 months in Southern Ethiopia found that responsive feeding was common; three in four tended to respond to the child’s hunger cues in a reasonable time, and twothirds encouraged the child to eat verbally or physically when the child refused. Illness in the child and change of caregiver were identified as causes of refusal to feed in the study. A laissez-faire mode of feeding which entails lack of extra effort at feeding by the care giver even when the child in question isunder nourished was less common in rural areas and in biological mothers(9).

Reduction in malnutrition rates is imperative if the battle to achieve MDG 4 is to be won. Many factors are responsible for the high level of malnutrition in Sub Saharan Africa. Understanding the factors behind poor infant and child feeding practices will assist in addressing these issues and ensure that the battle for child survival in the fastest growing population globally will not be lost.

Whereas well intended nutrition policies and guidelines exist there to be a much higher level of political pressure, social and community mobilization to realize increased uptake and acceptance and uptake in Sub-Saharan countries.

References
1. United Nations, Department of Social and Economic Affairs, Population Division (2013). World Population Prospects. The 2012 Revision. Key Findings and Advance Tables. Working Paper No ESA/P/WP.227
2. Levels and Trends in Child Mortality. United Nations Interagency Group for Child Mortality Estimation 2013 Report.
3. Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008 – 09. Calverton, Maryland: KNBS AND ICF Macro; Child health: 127 – 154
4. Rapid Qualitative Assessment. Beliefs and attitudes around Infant and Young Child Feeding in Kenya. January 2011
5. Hussein AK. Breast feeding and complementary feeding practices in Tanzania.East Africa Journal of Public Health Vol 2,No. 1, April 2005;27-31
6. Kalanda B, Verhoeff F, Brabin B. Breast and complementary feeding practices in relation to morbidity and growth in Malawian infants.European Journal of Clinical Nutrition 2006;60, 401-407
7. Webb- Girard A, Cherobon A, Mbugue S et al. Food Insecurity is Associated with Attitudes toward Exclusive Breast Feeding in Women in Urban Kenya. Matern Child Nutr 2012 Apri; 199 – 214
8. Saha K, Frangillo E, Alams D et al. Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh. Am J ClinNutr 2008; 87: 1852-1859
9. WondafrashM, Amsalu T,Woldie M. Feeding styles of caregivers of children 6 – 23 months of age in Deshare special district, Southern Ethiopia. BMC Public Health 2012; 12:235