Promotion of Complimentary Feeding Practices Through Health Messages: a Community-based Clustered Randomized Trial in Rural Bangladesh

Back ground:

Link between infant feeding practices and nutritional status among children has been well established. Incidence of malnutrition sharply rises during 6-9 months of age which coincide with the period of complimentary feeding (CF). It is reported that poor nutrition increases the risk of illness, and is responsible, directly or indirectly, for one third of the estimated 9.5 million deaths in children less than 5 years of age. Early nutritional deficits are also linked to long-term impairment in growth and health. There is evidence that adults who were malnourished in early childhood have impaired intellectual performance. They may also have reduced capacity for physical work. High proportion of childhood malnutrition has negative impact for national development. Based on evidence of the effectiveness of interventions, achievement of universal coverage of exclusive breastfeeding (EBF) could prevent 13% of deaths occurring in children less than 5 years of age globally, while appropriate complementary feeding practices would result in an additional 6% reduction in under five mortality. Although there is huge potential for EBF till 6 months of age, the CF practices is also important to maintain the increase demand and growth after the period of EBF to maintain the optimal growth and development during infancy and early child hood period. However, there are lacks of efforts observed to increase the knowledge of good complementary feeding practices at population level. Under five child mortality is still high for Bangladesh. Among these deaths prematurity of the newborn/LBW and malnutrition together contribute to about 45% of all deaths. Despite the progress achieved, child malnutrition in Bangladesh remains among the highest in the world, and more severe than that of most other developing countries. This suggests that children in Bangladesh suffer from short-term acute shortfall in food intake as well as longer-term under-nutrition. Exclusive breast feeding is quiet static (43%-46%) for last few years in Bangladesh and around one fourth infant from 6-9 months ages start complementary feeding either too early or too late. Inappropriate practices of CF reflect the knowledge gap at the population level. Mother and family members are usually unaware about the nutrition need immediately after the completion of exclusive breast feeding practices. It was reported that Bangladesh scored 91.5/150 for Young Infant and Child Feeding (YICF) practices which was done by International Baby Food Action Network (IBFAN), Asia Pacific where community outreach and information support warranted much improvement. To reduce malnutrition: Comprehensive programme of integrated actions on many fronts has been addressed which includes "Promoting improved infant feeding practices, including breast feeding practices". Mothers and families need support to initiate and sustain appropriate infant and young child feeding practices through support person or peer group is recommended at the community level. Educational intervention on CF practices shows improvement in several studies in India, china and Brazil. Indian study observed feasibility of CF practices promotion through existing system and found limited improvement of infant length (difference in means 0.32 cm, 95% CI, 0.03, 0.61) between groups. Brazilian study assessed impact on child growth of the nutrition counseling component of the Integrated Management of Childhood Illnesses strategy and found children 12 month of age or older had improved weight gain (changes of +.25 and -.06 Z-score, respectively) and a positive but non-significant improvement in length (0.40 vs. 0.12). In this study medical doctors were used for counseling which is not applicable in poor resource settings. The China study was to improve infant growth by improving infant feeding practices. The education group infants were significantly heavier and longer, but only at 12 month (weight-for-age -1.17 vs. -1.93; P=5 0.004; height-for-age -1.32 vs. 1.96; P =0.022). But this study differ from exclusive breast feeding (EBF) duration and starting of complimentary feeding practices as recommended by WHO (EBF is practice 4-6 month and weaning starts at 4 months). None of the above studies evaluated feeding practices through CF index. In early 90's Bangladesh Rural Advancement Committee evaluated educational messages on CF practices other than WHO recommendation, Population level study on CF practice promotion is poor in Bangladesh. Given the above background, with lack of knowledge on CF practices in the community level and high burden of childhood malnutrition, we plan to improve complementary feeding practices in Matlab.

Hypothesis to be tested:

The proposed study hypothesized that an appropriate delivery of CF messages at the community level will improve the CF practices and subsequently decrease the burden of malnutrition during infancy.

Specific objectives: