Improved nutrition during pregnancy, lactation, and early childhood are important ways to avoid micronutrient deficiencies, for both mothers and children.
Good maternal nutrition during pregnancy improves the birth outcomes of children and reduces the risk of pregnancy-related health complications (Black et al. 2013; Abu-Saad and Fraser 2010). Providing nutrition education and counseling during pregnancy is one way to improve maternal nutrition practices (WHO 2016), although good practices need to continue through lactation.
Infant and young child feeding (IYCF) is a critical component of the 1,000 days approach to improve child health. WHO recommends early initiation of breastfeeding (within the first hour), exclusive breastfeeding for the first six months of life, and timely and appropriate complementary feeding, with continued breastfeeding up to two years or beyond (WHO and UNICEF 2003). Exclusive breastfeeding reduces infant morbidity and mortality from common infections, such as diarrhea or pneumonia; and it indirectly reduces anemia by preventing the inhibitory effects of inflammation on iron absorption, mobilization, and, consequently, red blood cell production.
Complementary feeding starts at 6 months of age when breastmilk alone cannot meet the nutritional requirements of an infant, and other foods and liquids are needed with the breastmilk. The guiding principles of complementary feeding include (1) giving amounts of food that increase with the age of the child; (2) ensuring the food has the right consistency, nutrient, and energy density; and (3) ensuring the caregiver practices responsive feeding (WHO 2005; K. Dewey 2003). Ensuring dietary diversity in these early months of life when growth is rapid helps avoid micronutrient deficiency. Additionally, fluid intake should meet the daily requirements, micronutrient fortified foods should be used when available, and food and fluid should not be restricted during or after illness.
Measurement and data sources
The World Health Organization (WHO) defines a list of core and optional indicators to assess IYCF practices, which include—
Core breastfeeding indicators—
- early initiation of breastfeeding (percentage of children born in the last 24 months who were put to the breast within one hour of birth)
- exclusive breastfeeding (percentage of infants 0–5 months of age who are fed exclusively with breastmilk)
- continued breastfeeding at 1 year (percentage of children 12–15 months of age who are fed breastmilk).
Core complementary feeding indicators—
- introducing solid, semi-solid, or soft foods (percentage of infants 6–8 months of age who receive solid, semi-solid, or soft foods)
- minimum dietary diversity (percentage of children 6–23 months of age who receive foods from four or more food groups)
- minimum meal frequency (percentage of breastfed and non-breastfed children 6–23 months of age who receive solid, semi-solid, or soft foods—but also including milk feeds for non-breastfed children—the minimum number of times or more)
- minimum acceptable diet (percentage of children 6–23 months of age who receive minimum diet diversity and meal frequency).
- children ever breastfed (percentage of children born in the last 24 months who were ever breastfed)
- continued breastfeeding at 2 years (percentage of children 20–23 months of age who are fed breastmilk)
- age-appropriate breastfeeding (percentage of children 0–23 months of age who are appropriately breastfed)
- predominant breastfeeding under 6 months (percentage of infants 0–5 months of age who receive only water and water-based drinks, fruit juice, ritual fluids, oral rehydration salts, or drops or syrups—vitamins, minerals, medicines—in addition to breastmilk)
- bottle feeding (percentage of children 0–23 months of age who are fed with a bottle)
- duration of breastfeeding (median duration of breastfeeding among children less than 36 months of age) (WHO, 2010).
WHO created a comprehensive tool for assessing national practices, policies, and programs for IYCF; although, in the context of anemia, the indicators above are sufficient (WHO and LINKAGES Project 2005).
While less commonly collected in household surveys, minimum dietary diversity and minimal meal frequency for postpartum women can be calculated from surveys that include a section on postpartum dietary intake (USAID 2015). Similarly, questions on knowledge and practice of maternal nutrition messages and counseling may be available.
Surveys that sometimes collect information related to IYCF practice (and sometimes counseling or message delivery) include—
- Demographic and Health Surveys
- Multiple Indicator Cluster Surveys
- National Micronutrient Surveys
- Knowledge, Practice, and Coverage Surveys
- other research or evaluation activities.
Health monitoring information systems may include information relevant to maternal, infant, and young child nutrition programs, including early initiation of breastfeeding, breastfeeding status, or providing nutrition counseling. They may also capture and aggregate data on the nutritional status of children and mothers. This data may be collected during antenatal care visits (for maternal nutrition), at birth, during well-child/immunization visits, or during other interactions with health care providers.
- Age is an important factor in calculating these indicators. Most of the standardized national surveys have processes in place that ensure the child’s age is correct. If the indicator data is from a household survey, review the survey methods to ensure that the age data were properly calculated. Remember, some of the IYCF indicators depend on mothers’ recall to calculate the value.
- In the face of intensive behavior change and communication messages about IYCF, data collected through recall may be overestimated, because respondents will often be aware of ideal behaviors and may want to provide the “right” answer, even if they do not use the practice themselves.
- Children 0–5 months can be given oral rehydration salts and vitamin and/or mineral supplements, and still be considered exclusively breastfed.
Abu-Saad, Kathleen, and Drora Fraser. 2010. “Maternal Nutrition and Birth Outcomes.” Epidemiologic Reviews 32 (1): 5–25. doi:10.1093/epirev/mxq001.
Black, Robert E., Cesar G. Victora, Susan P. Walker, Zulfiqar A. Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, et al. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” Lancet (London, England) 382 (9890): 427–51. doi:10.1016/S0140-6736(13)60937-X.
Dewey, Kathryn. 2003. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC, USA: PAHO/WHO, Division of Health Promotion and Protection/Food and Nutrition Program.
Guyon A., Quinn V., Nielsen J., Stone-Jimenez M. 2015. Essential Nutrition Actions and Essential Hygiene Actions Training Guide: Health Workers and Nutrition Managers. Washington, DC: CORE Group.
USAID. 2015. “Maternal Nutrition for Girls and Women: Technical Guidance Brief.” https://www.usaid.gov/what-we-do/global-health/nutrition/technical-areas....
WHO and UNICEF. 2003. “Global Strategy for Infant and Young Child Feeding.” World Health Organization. http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/.
WHO. 2005. “Guiding Principles for Feeding Non-Breastfed Children 6-24 Months of Age.” Geneva, Switzerland: WHO.
———. 2010. Indicators for Assessing Infant and Young Child Feeding Practices Part 2: Measurement. Geneva, Switzerland: WHO.
———. 2016. “eLENA | Nutrition Counselling during Pregnancy.” WHO. Accessed September 7. http://www.who.int/elena/bbc/nutrition_counselling_pregnancy/en/.
WHO and LINKAGES. 2003. “Infant and Young Child Feeding: A Tool for Assessing National Practices, Policies and Programmes.” Geneva, Switzerland: WHO. http://www.who.int/nutrition/publications/inf_assess_nnpp_eng.pdf