complementary feeding: preventing the plunge marcia griffiths the manoff group

Complementary Feeding:Preventing the Plunge

Marcia GriffithsThe Manoff Group

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Malnutrition is a process

Nutritional Status Weight-for-Age

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The Pattern is Universal

Shrimpton, R. et al. Pediatrics 2001;107:e75

Pattern of Chronic Malnutrition

Shrimpton, R. et al. Pediatrics 2001;107:e75

Result of Early Insults

The Prevention Paradigm—an unfinished agenda

Lancet endorsement of complementary feeding promotion—education and supplementation

19.8% relative reduction in stunting 0-12mo.

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BF Complementary Feeding

Hygiene and Healthcare

The Complementary Feeding Balancing Act

Is age-dependent:

The 6 – 24 month group is not monolithic

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The Complementary Feeding Balancing Act

Multiple behaviors

and multiple paths to reach goal of improved nutrient intake

• Breastfeeding-----Complementary foods• Nutrient density-----Food consistency/dilution• Frequency of feeding----Nutrient density• Frequency of feeding----Quantity per feeding

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The Complementary Feeding Balancing ActRequires cultural and individual specificity

Example of feeding frequency: Different cultural practicesKazakhstan—feeding approx 10 x/day Marie Biscuits and teaC. America—feeding about 2-3 times, not in the afternoonGujarat—feeding once with 2 snacks, child should feel hunger

Individual tailoring:Mother works at home Mother is still fully breastfeeding

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How Are We Doing?

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Percent of Countries

Percent of Infants Meeting Indicator

Continue to Breastfeed (From 43 Countries)

Murkuria, A, et. al. 2006. Infant and Young Child Feeding Update. ORC Macro: Calverton, MD.

How Are We Doing? Adequate Dietary Diversity (from 37 countries)

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How Are We Doing?

Adequate Feeding Frequency (From 35 countries):

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How Are We Doing?

Composite of 3 practices

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How Can We Change This Picture?

Resources• Global Strategy on Infant and Young Child Feeding,

2002• Guidelines for the Complementary Feeding of the

Breastfed Child, WHO/PAHO, 2001• Guidelines for the Complementary Feeding of the

Non-Breastfed Child, WHO, 2005 • Indicators to track progress—WHO and DHS

• Tools to gather caregiver input on behavioral recommendations

Designing by Dialogue

ProPan• Old and new program strategies• Old and new technologies and products• Partnerships • Creativity

How Can We Change This Picture?

How to Strengthen Performance

1. Listen and learn from caregivers

2. Plan strategically

3. Improve access to quality food choices

4. Focus on practices including those not measured

5. Provide tools to help implementation of key practices

6. Provide tailored advice and demonstrations


1. Listen and Learn from caregivers• Big picture: DHS or other survey data• Explore REASONS behind reported practices

(determinants of current behavior)• Also explore reactions to new/modified behaviors

(determinants of new behavior)

Trials of Improved Practice

Three step home visit protocol:

1. Exploratory visit

- Analysis: rank feeding problems develop recommendations

2. Counseling/ negotiation visit

- TRIAL

3. Follow-up visit

Examples of Insights

• Green leafy vegetables: - difficult to digest (Indonesia)

+ bayam, finely chopped and well-cooked

• Animal Foods: - unaffordable (Swaziland)

+ father purchase/ duty to child

• High frequency of snacks: - child is too fussy/calms child (Kazakhstan)

+ a meal reduces fussiness

• Assisted feeding: - too busy, hard, child needs to learn

+ feed child/ animals; to learn; need to teach; if child eats takes less time later

Results

• Prioritize key elements among the many factors• See similarities and differences across a country

- Scale- up addressing common themes

- Develop regional or village variations where needed

How to Strengthen Performance2. Complementary feeding is behavioral, requiring a strategic

approach

Legislation•Code of marketing breastmilk substitute •Code of marketing infant foods- safety

Communication

•Advocacy for attention to child feeding•Promote critical child feeding concepts•Promote specific, over-arching, improved practices •Counseling•Demonstrating

Training

•Healthcare professionals•Develop a community cadre•Agriculture extension

Partnerships

•Private sector•Local vendors, shop owners•Women’s organizations

Products

•Local recipes•Home fortificant•Commercial food•Bowl, spoon•Tippy Tap


3. Improve access to as many quality food choices as possible:

home made combinations,

improved vendor foods,

home fortificants—powders and spreads,

commercially processed foods

Homemade Mixed Foods—Achievements

Indonesia: Homemade, Bubur campur

Zeitlin et al. 1984 Household Evaluation: Nutrition Communication and Behavior Change Component. Manoff International: Washington, D.C.

Homemade Mixed Foods—Achievements

Zeitlin et al. 1984 Household Evaluation: Nutrition Communication and Behavior Change Component. Manoff International: Washington, D.C.

Indonesia: Homemade, Bubur campur


4. Don’t forget about practices that are not part of an indicator

Ex. Hygiene,

Use of oil/fat

Responsive or assisted feeding, and

Food quantity per serving

Quantity is a problem that becomes acute in the second year of life.

Food QuantityFrom Honduras—2002

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Breastfeeding Frequency of Feedingper Recommendation

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Feeding According to Recommendations: Children 12-23 Months

Feeding According to Recommendations: Children 9-11 Months

Food Quantity--Issues• Caregivers have no idea how much a child should

receive• Caregivers do not think it is possible for a small child

to eat “so much”• Caregivers often report being afraid that their child

will get sick from eating “too much”• Sometimes caregivers say that they do not want their

child to get accustom to feeling full, to always being satisfied

• Counseling materials with pictures of the number of spoons of food needed at each meal not clear or memorable


5. Provide tools to help the implementation of critical practices

Ex. Child Feeding

Bowls

Countries:

Nicaragua

El Salvador

Bolivia

Child Feeding Bowls

• Bowl models have been different in each location• All have markings to denote appropriate quantity of

food for each age• The bowls allow a mother/older sibling to offer the

appropriate amount of food and to see how much the child eats.

Child Feeding Bowl--Trial

• In June/July 2008, in Santa Cruz area of Bolivia, use of bowl assessed

• Qualitative study using TIPs method• Bowl introduced to 28 of 82 participating mothers

whose children (6 – 22 mo) had especially poor reported food intake

Child Feeding Bowl--Result

• All mothers with bowls used them, and were successful in increasing food quantity to the amount indicated by the bowl for the child’s age.

“the bowl gives good results and my child eats more when he eats from his own plate. I can measure how much he eats and he likes the bowl”.

• Use of the bowl seemed to motivate improvement in other practices: feeding more frequently and separating the child’s food from the family’s.

Child Feeding Bowl--Result• Fathers took interest in the bowl and therefore in feeding their

child

• Older children took ownership of their bowls and asked for food

Child Feeding Bowl--Conclusion

• High acceptability—everyone wanted one• Made instruction/counseling easier• Served as an effective reminder about feeding• Inexpensive ($0.22 – $0.38)• Easily scaleable


6. Provide Tailored Advise and Demonstrations

• Mothers often don’t know what to do – advice is not easily available

• New concepts- ex. expansion of grains and food consistency

• New skills- mashing food, using greens, beans• Influence of internal barriers – sense of self

confidence and self- efficacy

Counseling Aids & Demonstrations

Counseling Skills

Counseling at Health Services-- Specific Advice on PracticesChildren meeting local energy requirement

Counseled Not Counseled

At 8 months 82% 73%

At 12 months 62% 51%

Stunting at 18 months: 5% 16%

• At 18 months children of “counseled” mothers- 1 cm taller

Penny, ME. et al. 2005. Effectiveness of an Educational Intervention Delivered Through the Health Services to Improve Nutrition in Young Children: A Cluster Randomized Controlled Trial. The Lancet, 365:1863-1872.

Improving Complementary Feeding

• It is our “opportunity” / our failure• Call for strategies: policies, programs and tools built

to answer local need • Programs will not look the same but they should

consider similar themes

• High coverage• Are key practices improving?• Are nutrient intakes improving?• Is the growth failure gap narrowing?

Improving Complementary Feeding– The Bottom Line

Will these two children experience the same outcome?

complementary feeding: preventing the plunge marcia griffiths the manoff group

Documents

young child feeding

adequate feeding frequency

orc macro

nonbreastfed child

new technologies

home mother

caregiversbig picture

new program strategiesold