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Programmatic approaches to improve complementary feeding practices
Cultural perceptions
Before attempting to promote changes in current child-feeding practices, it is crucial to understand the local beliefs governing them. Technical recommendations based strictly on the physiological considerations described above may be unacceptable if they are incompatible with local perceptions. For example, beliefs about the appropriate age to introduce complementary foods and the types of foods that are acceptable must be taken into account. In the following section, these issues are discussed briefly in the context of different studies carried out in Peru.
Age of introduction
In Peru, the perceived appropriate age for the introduction of complementary foods is related to the caregiver's notion of when the child is ready to eat. This, in turn, is generally viewed in terms of the child's development: the presence of teeth, the "forming of the stomach," the ability to swallow food, or the demonstration of an active interest towards food. Recognition of these characteristics varies according to cultural setting. In coastal communities, an infant may be perceived as wanting to eat or needing to begin "forming the stomach" as early as 2 to 4 months of age; in rural highland populations, this is perceived to occur at 8 to 10 months, and the process of "forming the stomach" can last as long as 4 months. In each case, there is a concept that foods must be introduced gradually.
Types of food
Peruvian caregivers generally select more dilute preparations as first foods because they are considered easier to swallow and appropriate for "forming the stomach." Broths and soups are perceived as being especially valuable because the nutritious components of the food ingredients are "extracted" into the broth during cooking. Certain foods are considered more appropriate for small children, such as milk, chicken liver, and, to a lesser degree, egg. Yellow foods, such as squash or a local variety of banana, are also considered beneficial. On the other hand, some foods, such as beans and oil, are perceived as possibly causing harm. In some cultures, these perceptions are related to the humoural system.
Types of complementary food preparations
Improved complementary feeding regimens may incorporate home-prepared combinations of easily accessible foods; pre-cooked, centrally processed food mixtures; or "hybrids" of these two approaches. The relative advantages and disadvantages of each approach have been described [80]. Experience with each of these types of interventions in Peru will be described.
Home-available mixed diets. There have been a number of recent attempts to promote improved home-prepared complementary foods in Peru. In each case, the interventions were developed in a stepwise fashion following a series of preliminary "formative" research activities. First, an understanding of the critical cultural concepts mentioned above was sought through interviews with key informants and discussions within focus groups composed of child caregivers.
Foods were then selected on the basis of their availability at the household level, their nutritional value, their cultural acceptability, and their cost (in the case of those that must be purchased). To ensure maximum efficiency, the cost per nutrient value was calculated periodically on the basis of the local market price for the candidate foods, and those providing the greatest energy or nutrient value at least cost were incorporated preferentially in the food mixture.
Food preparations or recipes using the selected foods were formulated through a participatory process of recipe trials with the beneficiaries [81]. Behavioural change trials of the use of these preparations in the home were then conducted to explore the acceptability of the recommended foods and feeding practices, and any necessary modifications were made [81, 82].
Using this methodology, improved child feeding practices were promoted at the community level in a shanty-town population of Lima, using a mix of interpersonal (video and demonstration), print, and local alternative media to promote appropriate complementary feeding concepts and recipes. The objectives of the intervention were to postpone the introduction of non-breastmilk foods until at least five months of age, encourage continued breastfeeding through the first year of life, and promote consumption of at least two portions daily of the recommended complementary food mixtures, with or without additional snacks or other foods.
The complementary food mixtures were described both as specific recipes and in terms of improved preparation techniques, such as making thicker purees and puddings rather than broths and soups. No specific recommendations were given on the total number of feedings during the day, because this was not originally considered a principal problem in Lima.
The intervention achieved a significant delay in the timing of the introduction of foods, although the magnitude of change was modest. After the intervention, 37% of the population had introduced non-breastmilk foods before five months of age, compared with 54% at baseline. There was a significant increase in recommended complementary feeding practices from 15% of the population to 28% after the intervention. The concept of a thick food as nutritious appeared to be adopted more readily than the specific recipes promoted. Among the specific recipes, savory purees were preferred over sweet puddings. The use of energy- and nutrient-dense snacks, such as bread and biscuits, was a common practice reinforced during this intervention.
In another project, designed initially to improve the dietary management of diarrhoea (DMD project), a recipe for a home-prepared mixture, "Sanquito," was developed and promoted for use in children during and after diarrhoea in a highland region of Peru [81]. Sanquito was a modification of a local preparation of wheat flour, sugar, and lard or oil, which was nutritionally improved by incorporating pea or broad bean flour and carrot. After five months of a pilot educational intervention conducted through a mix of radio, print, and face-to-face communication channels, 82% of the population had attained knowledge of the recipe, 16% had prepared it, and 12% reportedly used it regularly (S. Esrey, personal communication, 1989).
Considerably higher levels of trial and adoption occurred when the messages were received from a doctor or nurse or, to a slightly lesser extent, through a mothers' club, indicating the importance of interpersonal communication for use of the recipe. As Sanquito was promoted for treatment of diarrhoea, the presence of a recent episode of diarrhoea in the index child was associated with its use; children who had not had diarrhoea during the intervention period rarely had received the mixture.
As a result of the experience of the DMD project, a programme was subsequently implemented in an oral rehydration unit in a hospital in Lima to promote adoption of complementary feeding recipes for children admitted to this unit. A health facility was chosen for the intervention, not to make recommendations specifically for diarrhoea, but because health workers were shown to be a credible source of information in the DMD project. Also, it was assumed that the caregivers' heightened attention to the children's needs at that time might favour adoption of the nutrition message [83].
Two different educational approaches were used: one group of mothers received five minutes of counselling and a recipe pamphlet, the other group received the same counselling plus a 20-minute cooking demonstration. In both cases there was a significant impact on mothers' knowledge both at 48 hours and again at 30 days after the intervention (from 28% before the intervention to 74% and 75%, respectively, afterwards). Likewise, use of the promoted recipes at least once on the day before the interview increased from 3% to 58% and 38%, respectively, during the two follow-up assessments, which were conducted by 24-hour recall history. Interestingly, there was no difference between the two educational methods with respect to either of these outcome variables.
Centrally prepared complementary foods. Usually, centrally produced complementary foods are precooked, industrially processed mixtures that are distributed for community-based supplementary feeding programmes, home use, or both. Alternatively, mixtures of local foods may be cooked in community kitchens or feeding centres for distribution within the community. In both cases, responsibility for the formulation of the food mixture no longer remains with the individual caregiver.
Nevertheless, the caregiver must choose whether or not to participate in the programme and, in some cases, whether to prepare and serve the previously formulated mixture at home or in the community feeding centre. Until very recently we have had very little experience with precooked, industrially prepared formulations in Peru. However, we have attempted to promote improved complementary feeding practices through community kitchens, as described in the following section.
During a pilot project in Lima, complementary foods were prepared three times a day in community kitchens, where they were then collected by young children's caregivers or siblings. This permitted savings of time, fuel, and money, and further served as a way of demonstrating appropriate complementary feeding practices [84]. In this study, daily energy intake following the intervention period was significantly greater in the intervention than the control group (100% versus 74% of FAD/WHO 1985 requirements for body weight for children 6 to 24 months of age). The mean total daily energy density (including breastmilk) was also significantly greater in the intervention than in the control group (81 versus 69 kcal/100 g). Participating children received 32% of their total daily energy intake from the community kitchens. Interestingly, there was a positive correlation between change in height and weight during the intervention period and the total number of rations received from the community kitchens.
In areas where appropriate ingredients for complementary foods are not easily accessible to high risk households, it may be necessary to prepare and distribute nutritionally fortified mixtures. Before initiating these programmes, acceptability trials need to be conducted and effective distribution channels identified or developed. Strong educational components are needed to ensure that the food is appropriately prepared and reaches the target group.
Methods of promotion: Education and communication
Communication channels
A combination of communication channels, including both mass media and interpersonal contact, is important for the motivation, dissemination of information, and training necessary to promote optimal complementary feeding practices. In the previously described community-based interventions, a combination of media were used: radio, print material, and face-to-face education.
In the DMD project, radio messages were instrumental for transmitting knowledge, but they needed to be complemented with one or more additional interpersonal channels to achieve trial or adoption. In the Lima community intervention, there was no association between adoption and specific communication channels; nevertheless, a more favourable attitude toward the feeding messages was associated with exposure to the video and demonstrations. In Peru it was important to include health professionals as "agents of change" because they are considered credible sources of information. Face-to-face communication in the clinical setting was found to be an effective way of teaching the enhanced complementary feeding recipes.
Community organizations
Existing community organizations are potentially valuable channels for communication and intervention programmes. They can also be a useful base for distribution of centrally prepared foods, as shown in the community kitchens project. In the DMD project, belonging to a community organization was associated with higher trial and adoption rates. However, in Lima, where multiple organizations serve the same communities, it was necessary to work with several community groups simultaneously to achieve adequate coverage.
Specific recipes versus general advice
Specific recipes were developed in each of the interventions described above. In some cases, concepts of appropriate food preparations for young children were also explained. For example, the importance of thick consistency, combinations of foods, and the use of animal products when available was emphasized. The acceptance of specific recipes versus general recommendations varied in the different projects. Mothers commented that they liked to have the recipes; however, more research is needed to explore which of these approaches might produce the greatest long-term impact on feeding practices.
Sustainability
Changes in child-feeding behaviours occur slowly and tend to revert to pre-existing practices if the new behaviours are not continuously reinforced. Thus, the sustainability of intervention programmes is critical in promoting long-term changes in feeding practices. Moreover, those segments of the target population in greatest need of improved feeding practices are often the most resistant to change. Interventions must be continued for even longer periods of time to reach these "late adopters." In each of the above-mentioned interventions, with the exception of the community kitchens trial, the recommended practices diminished with time as the caretakers forgot the new practices. In the hospital intervention, 30 days after receiving the recommendations, use of the recipes had diminished, even though levels of knowledge had not changed. Interestingly, in the community interventions people requested a continued presence of nutrition advisers. Thus, effective ways of institutionalizing these educational interventions need to be identified.
Constraints to adoption of improved feeding practices
From the above studies, a picture of the "adopters" has emerged. In two of the studies, the mothers of younger children (5-7 months of age) were found to be more likely to adopt the recommended practices than mothers of older children who were believed to be "already accustomed to soups." Caregivers who adopted the recommended feeding practices also tended to be younger mothers, those with less advanced schooling, and those who lived independently of their own mothers or mothers-in-law. Participation in a community organization was associated with higher levels of adoption in the DMD highland intervention, although this was not the case in Lima, probably because many more community organizations exist in the capital. A brief description of specific constraints to adoption follows.
Cost and availability of foods
A lack of certain food ingredients may be a constraint to the use of appropriate complementary foods. This seems to have been the case with Sanquito, where pea or broad bean flour was found in only 38% of homes at the time of the evaluation. In the community kitchens project, the more expensive chicken liver was replaced by egg in some of the recipes. Similar constraints of food availability or cost have been reported elsewhere [85].
Caretaker time
An essential quality of complementary foods is that they must be easily prepared, as extra time for the preparation of special foods for the young child rarely exists. The community kitchens project successfully addressed this constraint by providing a prepared food three times a day. Selecting food from the family pot saves time for home-prepared mixtures. Possibly for this reason, purees, which were generally made from ingredients already present in the soup prepared for the whole family, were more acceptable than the specially made puddings in the Lima community intervention. Time was not reported as a limiting factor in the preparation of Sanquito, which took only eight minutes.
Cultural beliefs
Local perceptions about the acceptability of specific foods for young children or the appropriateness of combining different ingredients may have influenced adoption of the recommended practices. The concept of the addition of oil or margarine to the infant's food was not well accepted in the community interventions. In the Lima community intervention, when fat sources were included in the recipe, they were given in smaller than recommended amounts and added only in the savoury dishes. In the DMD recipe, oil was the ingredient most frequently forgotten, and when not, it was used in less than recommended amounts. Consequently, promoting this ingredient of complementary foods in this setting has to be reviewed.
Conclusions and future research needs
Age of introduction of complementary feeding
Full-term infants with appropriate weight for gestational age should be exclusively breastfed until six months of age. This same recommendation is probably appropriate for term infants who are small for gestational age ( < 2,500 g), unless they are so underweight that they are too weak to suck, or their mothers are severely undernourished. However, more information is needed before authoritative programmatic recommendations can be formulated for low-birth-weight infants. More information is also needed from intervention trials on the relationships between maternal nutrition status and the volume and composition of breastmilk, and on the micronutrient status of infants who have been exclusively breastfed for six months. The desirability of maternal and/or infant supplements needs to be determined.
Frequency of feeding complementary foods
Recommendations on feeding frequency must consider the trade-off between the additional caregiver time required for each meal and the greater intakes achieved with more frequent feeding. It seems that at least four meals per day for non-breastfed children would be ideal to avoid the need for very high density foods. This frequency of feeding was already being achieved in the two case-study sites in Peru and Nigeria by about half the caregivers of breastfed children, who conceivably might require a lower meal frequency than fully weaned children. If this frequency of meals is not feasible, the energy density of foods must be enhanced appropriately to assure adequate total energy intake.
The experimental studies that provided information on the relationships among feeding frequency, energy density, and total energy intake were conducted in fully weaned children. Further intervention studies are needed to determine if these recommendations are also appropriate for infants and younger children who are still breastfeeding.
Energy density of complementary foods
As indicated above, it is uncertain whether current information on the minimal acceptable energy density of foods for non-breastfed children can be applied to those who are still receiving breastmilk. Among non-breastfed children, a minimal energy density of 120 kcal/100 g seems appropriate if only three meals are offered per day. If four meals are provided daily, a minimal energy density of 85 kcal/ 100 g should be acceptable. Additional studies are needed in healthy, well-nourished children to confirm these tentative recommendations. Likewise, data are needed on the appropriate energy density of complementary foods provided to breastfed infants and young children.
Micronutrients
Recent studies indicate that the quality of the diet (micronutrient content and bioavailability; proportion of energy from animal products) may be an important determinant of energy intake and growth in some settings. This creates a practical dilemma in many countries, because high-quality foods may not be accessible to those children with the greatest need, either because the foods are simply not available locally or because their cost is prohibitive. Information is needed on whether the overall quality of the diet can be successfully enhanced by fortifying common foods with an appropriate mix of nutrients or by providing micronutrient supplements.
Microbial contamination
Water, foods, feeding utensils, and caregivers' hands are frequently colonized by potentially pathogenic organisms excreted in faeces. Children's foods must be prepared with uncontaminated ingredients or heated sufficiently to destroy microbial contaminants, especially after prolonged storage of previously cooked foods. Research on novel, low-cost ways to prevent microbial contamination is needed.
Home-available vs. centrally processed foods
Programmatic interventions to improve complementary feeding practices may rely on optimal use of foods accessible to the household or on specially processed foods. In the long term, the first approach would presumably be more sustainable. However, suitable foods may not be available or may require supplementation or fortification with particular nutrients. Careful, controlled evaluations of the impact of different programmatic interventions are needed.
Promotion of Improved complementary feeding practices
Before interventions are initiated to improve current infant- and child-feeding practices, it is critical to characterize current feeding beliefs, behaviours, and available foods. Educational messages should be carefully formulated and disseminated through multiple local channels, including mass media and interpersonal forms of communication. Information is needed on which assessment techniques can provide useful information most reliably, quickly, and cheaply. Evaluations are needed of the particular educational techniques that are most successful and most efficient in producing the desired changes in feeding behaviours. Finally, programmes must be continued for long periods of time to ensure that any changes in behaviour will be sustained after the initial intervention is over.
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