5

Infant and Young Child Feeding

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Introduction
Supporting households in the production of optimal infant and young child nutrition status is a critical objective of many World Bank projects. Immediate determinants of young child undernutrition include inadequate dietary intake and excessive disease. Underlying these immediate causes are myriad behaviors (including hygiene practices and utilization of health care) and lack of basic social infrastructure (water and sanitation). This section provides information about the particular caregiving behaviors associated with the feeding of young children frequently the cornerstone of optimal nutrition even in the presence of severe resource and environmental constraintsincluding ideal practices and common feeding problems. The text and tables come primarily from Designing by Dialogue: Consultative Research for Improving Young Child Feeding by Dickin et al. 1997.

Lessons of experience
Which child feeding practices to target for change? Field experience in varying regions shows good results in the following areas: When to introduce non-breast milk food and liquids (complementary foods) Nutrient density of complementary foods Frequency of meals/feedings Active feeding of reluctant eaters Another important finding from projects in countries such as Cameroon and Indonesia: Mothers are willing to change feeding behaviors, and can do so quickly.

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Ideal feeding practices

Table 5-1 outlines ideal feeding practices and the common feeding problems associated with infants from birth to < 6 months, young children 6 to 23 months, and sick children.1 In early infancy (0 to < 6 months), exclusive breastfeeding with adequate frequency of feeding times is the optimal feeding pattern.2 Frequent problems encountered are: Delayed initiation of breastfeeding, prelacteal feeds, and supplementation with water and other liquids, poor positioning during breastfeeding, inadequate familial and societal support, poor maternal diet, and lack of information and counseling to overcome breastfeeding difficulties. From 6 to 8 months, children are in transition to complementary feeding. The first solid foods are added to the diet to augmentnot replacetheir breastmilk intake. Although the concentration of a number of nutrients naturally decreases during this period, breastmilk from a well-nourished mother remains the primary source of protein (up to 80 percent), vitamin A, folate, and vitamin C. In addition to displacement of breastmilk, the main problem at this stage is inadequate energy and nutrient density of complementary foods. Complementary foods provide the primary source of calcium, iron, and zinc;3 they also contribute to thiamin, riboflavin, and
1. Age is indicated in terms of completed months; 0 < 6 months is equivalent to 1 8 2 days or 6 full months. 2. Full-term infants with appropriate weight for gestational age should be exclusively breastfed until six months of age. According to Brown et al. (1995), exclusive breastfeeding for the same length of time is probably appropriate for term infants who are small for gestational age (< 2500 gms), . . . 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. 3. WHO, 1998 suggests that iron and possibly zinc and calcium requirements for older infants and young children (612 months) cannot be met without supplementation and/or fortification of complementary foods.

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Table 5-1: Ideal Feeding Practices and Common Feeding Problems by Age Group or Illness Status
Age (mos.) 0 to < 6 Ideal Practices Initiation of lactation within one hour of delivery; exclusive breastfeeding (no water, teas, juices, other liquids or solids) on-demand and frequently, day and night. Common Feeding Problems Delayed initiation of breastfeeding. Giving prelacteal feeds in place of colostrum. Feeding water, milk, or other liquids, usually by bottle. Premature introduction of complementary foods because the mother feels her milk is insufficient to nourish the baby. Dilute or watery, contaminated foods with low nutrient density. Delay in introducing complementary foods.

6 to 9

Continued breastfeeding. Gradual introduction of soft, nutritious, hygienic complementary foods.

9 to 12

Continued breastfeeding. Increasing Low frequency of feeding. variety of foods, including mashed fam- Low nutrient density: starchy or ily foods, fruits, and vegetables. 3 to 4 dilute foods continued. feeds per day of about 150200 kcal. Lack of variety. Family meals, plus snacks or special foods between meals. Up to five feeds per day of about 150200 kcal. Continued breastfeeding. Inadequate amounts consumed per meal (small servings, lack of supervision, lack of appetite). Lack of variety (lack of protein and/ or micronutrients). Low frequency of feeding. Childs refusal or lack of interest in eating. Lack of persistence or coaxing of a child with poor appetite. Quantity consumed is unknown; child is not given own serving of food. Breastfeeding and feeding dramatically reduced or stopped. Period of convalescence not recognized.

12 to 23

6 to 23

Careful monitoring of childs intake; encouragement and assistance with feeding to ensure adequate intake.

Sick child Continue or increase frequency of breastfeeding. Continue feeding regular foods or switch to soft foods. Provide special foods or more food for several days once child feels better.
(Adapted from Dickin et al., 1997)

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niacin intake. Frequently, the foods given to children are too dilute to provide adequate numbers of calories or amounts of protein, vitamins, and minerals. Delayed introduction (later than 6 months) of complementary foods is another common problem. Children of 9 to 11 months need increasing amounts and varieties of solid foods in addition to breastmilk. Meal frequency becomes an additional problem at this stage. Childrens stomach capacity is still small (ranging from 200400 gms),4 and 3 to 4 feeds a day are needed to accommodate their increasing energy intake needs. Traditional weaning foods are often bulky and viscous (or conversely too watery) as well as lacking in energy, making adequate intake unlikely for young children. Low energy and nutrient density of feeds as well as lack of variety can result in diets deficient in energy, protein, iron, vitamin A and other micronutrients. It is important to continue breastfeeding; breastmilk is a good source of energy through 23 months. For children in their second year of life (12 to 23 months), the same issues persist. Frequently there is need to increase total food intake (breastmilk consumption may be tapering off significantly) through frequent feeds of adequate amounts of varied, nutrient-dense foods. Throughout the early childhood years, caregivers (parents, elder siblings, other relatives) need to adopt active feeding styles. In addition to being easily distracted or anorexic at times, children frequently have to compete for food at the family table. If a single pot of food holds the meal for the entire family, food preparation may not be age appropriate and the youngest children may be unable to obtain adequate amounts on their own. At each developmental stage (frequently, but not always correlated with a specific age) the childs psychomotor abilities should dictate feeding
4. Gastric capacity is estimated to be approximately 3 percent of a childs total body weight.

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style (for example, when manual dexterity has developed at approximately age 15 to 18 months the child can hold a spoon and experiment with self-feeding). The caregiver must feed responsivelymaintain eye contact with the child and actively speak to/with the child during feeding, guide child participation in self-feeding activities and respond appropriately to child hunger cuesto achieve maximum dietary intake. Insure the optimal feeding environment (for instance, in a shaded, relatively quiet spot if outdoors) to determine successful feeding experiences. In the case of sick children, both health workers and families may be unaware of the need to continue feeding and how to overcome the resistance of children to eat during illness as well as the need to increase dietary intake during the recovery period (recuperative feeding).

Constraints to improving feeding practices

Dickin et al (1997) classify constraints as environmental (unavailability or seasonal variability of certain foods, the need to work outside the home which decreases time available for food preparation and feeding, scarcity of cooking fuel or communication of misinformation by health workers about child feeding) or attitudinal (perceptions, beliefs, and taboos related to feeding). Some common attitudes that negatively influence child feeding practices are perceived breastmilk insufficiency or inferior quality and perceived inability of child to swallow or digest particular foods. Lack of maternal self-confidence and feelings of powerlessness against childrens resistance to eating as well as traditional food distribution rules within the household may be responsible for negative feeding behaviors. Fear of spoiling the child with excess quantity of foods or with special foods may also cause problematic feeding practices.

Motivating for change

In addition to key beliefs and attitudes (both supportive and constraining) about young child feeding, it is important to discoverthrough qualitative

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research methodsthe motivations that fuel parents and caregivers feeding behaviors and their willingness to change. Individual motivation generally reflects a combination of personal beliefs and information and guidance from influential people within the family or community. Understanding the possible motivations for feeding behavior change will help to determine program communication strategies and techniques for health and nutrition counselors. Examples of motivations for improved child feeding practices include parental desire to do what is best for a child, the concept that healthier, better-nourished children perform better in school, less crying comes from a satisfied child, there will be less illness, and lower healthcare costs.

Dietary analysis for young children

Analysis of dietary information collected during baseline nutrition surveys or pilot project evaluations can be used to 1) determine adequacy of the diet and the associated positive and negative feeding practices, 2) identify deficits of particular nutrients, and 3) monitor impact of behavior change interventions on young child feeding behaviors. Generally, exact quantification of each childs intake is not the goal, but rather to make judgments about such questions as: Are breastfeeding practices adequate? Are meals and snacks fed with enough frequency? Are serving sizes large enough? Are foods too dilute or too bulky? Is there enough variety in the diet to provide adequate amounts of protein, vitamin A, iron, and other essential nutrients for growth and development?

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Are traditional food processing methods such as germination, malting, and fermentation5 in evidence; can they be promoted or enhanced to improve young child feeding practices? There are three types of calculations in the assessment of a young childs diet: 1. Dietary requirements for energy, protein and vitamins and minerals, 2. Estimates of the portion of these requirements being provided by breastmilk, and 3. Estimates of the portion of these requirements that must be provided through complementary foods. Nutrient requirements To determine adequacy of a childs diet, compare individual dietary intake information with established nutrient requirements by age. Table 5-2 provides information on approximate energy requirements and Table 5-3 contains estimates of other essential nutrient requirements. Contribution of breast milk From 6 to 23 months, a childs diet should be a combination of breast milk and other foods. Table 5-4 gives estimates of the energy provided by

5. Germination is the process of causing cereals or legumes to begin to grow. Malting adds the step of drying to germinated grains. Fermented foods are produced by allowing the multiplication of harmless bacteria before or after cooking. All three processes reduce the amount of phytate in the grains, increasing the absorption of nutrients such as non-heme iron and zinc and inhibiting the growth of harmful bacteria at the same time. These grains make thinner, less bulky porridges, allowing for increased intake by young children.

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Table 5-2: Recommended Energy Intakes During the First Two Years of Life
Recommended Energy Intakes a kcal/kg/day kcal/day Age Groups (in months) 02 88 404 35 82 550 68 83 682 911 89 830 1223 86 1092

a. Based on energy required for total energy expenditure plus growth of breastfed infants through 11 months. 12-23 months figures are based on energy required for total energy expenditure plus growth. (WHO, 1998)

Table 5-3: Other Nutrient Requirements During the First Two Years of Life
Age Groups (in months) Nutrient Protein (g/day) Vitamin A (mg RE/day) Iodine (m/day) Calcium (mg/d) Folate (m/day) Iron (mg/day) Low bioavailabilitya (5%) Medium bioavailability (10%) High bioavailability (15%) 02 9.6 350 50 525 16 35 8.5 350 60 525 24 68 9.1 350 60 525 32 911 9.6 350 60 525 32 1223 10.9 400 70 350 50

21

21

21

12

11 7

11 7

11 7

6 4

a. See explanation of iron bioavailability, chapter 3, p 58. (From WHO, 1998)

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Table 5-4: Approximate Energy Requirements and Energy Supplied by Breast Milk and Other Foods by Age Group among Children in Developing Countries
Total Energy Requirement (kcal/day) 404 550 682 830 1092 Energy from Average Breastmilk Intake (kcal/day) 437 474 413 379 346 Remainder to be Provided from Complementary Foods (kcal/day) 0 76 a 269 (275) a 451 (459) a 746 (750)

Age Group (months) 02 35 68 911 1223

a. The average estimate suggested for purposes such as general guidelines. Adapted from (WHO, 1998, p.51)

breastmilk and remaining energy demands by age group. In the 0 to < 6 month interval, breastmilk alone, under nearly all conditions, will provide adequate amounts of energy as long as exclusive breastfeeding is practiced (frequent, on-demand nursing with no additional non-breastmilk liquids or solids offered). If frequent breastfeeding (i.e., no long intervals between feeds throughout the 24-hour period) is not practiced in the population being studied, the estimated energy from breastmilk will need to be adjusted to reflect the populations breastfeeding patterns. Table 5-5 can be used as a om br eastfeeding. guide to estimate caloric intake fr from breastfeeding.

Contribution of complementary foods. After calculating the approximate amount of energy in the diet contributed by breastmilk, the remaining energy needs will be met with complementary foods (see fourth column, Table 5-4). The same process applies to estimates of dietary adequacy for other nutrients as well. Meal/feeding frequency, energy and/or

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Table 5-5: Estimates of Energy Consumption from Breastmilk

Breastfeeding Frequency 68 times/24 hours 46 times/24 hours 34 times/24 hours 13 times/24 hours
(Dicken et al., 1997)

Estimated Energy Contribution (kcal/day) 400 kcal 300 kcal 200 kcal 100 kcal

micronutrient density of food, and the amount consumed at each feeding are the three variables that influence the total figure for energy and other nutrients consumed in the diet. Energy density is the amount of energy or calories (kcal) per 100 grams of food eaten. The amount consumed at each feeding is limited by the gastric capacity of the child (approximately 200400 ml for young children)6. Feeding frequency indicates total number of meals and snacks consumed throughout a 24-hour period. The balance of these three variables changes, depending on food availability, eating customs and taboos, caregiver time allocation to food preparation and feeding activities, child morbidity and anorexia, and so forth. Table 5-6 presents sample data to help with the identification of problematic feeding behaviors (e.g., too few servings of insufficiently energy-dense foods) and possible solutions to young child feeding behaviors It is helpful to look at an example (Dickin et al., 1997) of the potential trade-offs among the three variables (energy density, frequency, and
6. A small cupful of porridge is approximately 150 ml.

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Table 5-6: Examples of Amounts and Number of Servings Needed for Foods of Different Energy Densities
Maximum Age Serving Number Group Size of (months) (ml) Servings 68 ~200 3 4 5 3 4 5 3 4 5 Amount (in grams) Needed per Serving, by Energy Density 50 kcal/ 100g not possiblea 200 160 not possiblea 250 200 not possiblea not possiblea a 300 100 kcal/ 100 g 130 100 80 170 125 100 250 200 160 200 kcal/ 100 g 70 50 40 80 60 50 130 100 80

911

~250

1223

~300350

a. Not possible indicates that the amount of food needed per serving exceeds the estimated maximum serving size. (Dicken et al., 1997)

amount of meals/snacks). If an 8 month-old child consumes only a teacupful (200 ml) of porridge with an energy density of 50 kcal/100g at each meal in addition to breastmilk, the porridge must be eaten four times a day in order to meet the childs energy requirements. For older children (>11 months), this porridge could only meet their energy needs if they consumed it in quantities beyond their gastric capacity, and more frequently than is possible in a day. Solutions to these problems include modifying recipes (for example, increasing energy density by frying or adding oil),7 encouraging additional meals of energy-dense foods, offering more food at each meal, and adding snacks between family meals. If

7. Recent research (Brown et al, 1995) points to the need for precision in identifying the determining factors for each childs specific nutrition status problem. While adding oil to a traditional weaning pap or gruel increases the energy density, it also displaces other nutrients, resulting, for example, in decreased protein and iron concentrations.

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the foods usually consumed by young children have fewer than 65 kcal/ 100g, priority should go to actions to increase their energy density.

Catch-up growth
The phenomenon of catch-up growthrapid growth following a period of undernutrition due to a variety of causes such as diarrheal disease, heavy worm loads, anorexia, lack of foodis characterized by increased appetite, and higher food intake requirements. If energy-dense, nutritious food is available, children can gain as much as 1020g a day for each kilo of body weight. Caregivers should be aware of catch-up growth and the increased need for more frequent meals of energy/nutrient-dense foods for a period following recovery from illness and/or undernutrition.

Supplementary feeding of young children

Food supplementation programs are a familiar vehicle for treating and preventing malnutrition among young children, particularly under emergency conditions and as part of maternal/child health programs. The World Bank has established the legal basis for financing of food expenditures in projects (see World Bank Directive on Financing of FoodOP/BP 10.00, May 22, 1996). Readers are directed to Food Supplementation (Toolkit #5) and School Nutrition (Toolkit #10) for detailed treatment of the two subjects; basic facts and figures are excerpted here for quick reference. Supplementary feeding of vulnerable children can be accomplished through take-home rations, food vouchers or coupons, and on-site feeding programs. The main short-term objectives of supplementary feeding interventions are the prevention of undernutrition including improved growth and development of vulnerable children and treatment of existing undernutrition (therapeutic feeding). For school-age children, reduction of shortterm hunger and improved school performance are additional objectives. Longer-term objectives include the reduction of childhood morbidity and mortality along with reduced prevalence of undernutrition that will ultimately contribute to stronger, healthier, more productive adults.

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Decisions for project design concern identification of the target population (and selection of feeding sites), plans for distribution (on-site or takehome rations), what foods will be distributed, and the logistics for food purchase, preparation or distribution, and storage. In general, locally supplied foods are considered superior to food aid commodities. Use of local foods provides familiar tasting meals, communicates lessons about recipes for improved complementary and convalescent foods, may encourage local food crops production, and reduces transport and storage costs. Seasonal availability of certain foods may be a problem. Food aid commodities have some advantages: They are often fortified with vitamins and minerals and are usually available in large quantities. Problems with donated foods include the creation of unsustainable demand for foreign food as well as the reverseunfamiliar food items may be rejected on the basis of taste and lack of experience with preparing meals from the foods. There are frequent logistical bottlenecks in the delivery system and food may be available for only a limited time. Transportation and storage costs may also be quite high. Whatever the source of the supplementary foods, FAO (1993a) recommends that a maximum of six types of donated food be included in the food basket. Use of dried milk Dried milk (most often skim milk) is a fairly common component of donated food shipments and a valuable source of protein and calcium. It may also have deleterious side effects, and needs to be administered with care (see Box 5-1). Rations: Summary recommendations A common objective of feeding programs is closure of the gap between what is consumed and what is actually required to meet daily energy (and/or other nutrient) needs. Assessment of what these needs are is covered in the section below on data collection. FAO (1993a) suggests guidelines for rations in non-emergency feeding programs as follows:

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Box 5-1: Dried Milk: Recommendations for Use in Feeding Programs for Young Children, Primary Schools, and During Emergencies
Dangers associated with the use of dried milk products in feeding programs include the following: Use of contaminated water to reconstitute dried milk may result in diarrhea and other infections. Bacteria multiply quickly in liquid milk especially if kept at a warm temperature. Dried milk may be too dilute or too concentrated as a result of improper reconstitution (both at on-site feeding programs and in the home). The availability of dried milk may discourage breastfeeding, especially if it is included in take-home rations. For these reasons it is recommended that: Pulses, meat or fish are used instead of milk as a protein-rich food whenever possible for both take-home and on-site feeding programs. Dried milk is never given to lactating women. If, for some extraordinary reason it is impossible to breastfeed a baby, an infant formula or whole dried milk should be used and fed by cup. Dried skimmed milk is not a suitable food for this purposeit is too low in fat and therefore energy. Dried milk is included in the food basket only in areas where milk is a culturally accepted item of diet. Only dried milk fortified with vitamin A is distributed. If dried milk is an item of the food basket, it is used in the following ways: For on-site feeding. Dried milk should not be reconstituted unless used under medical supervision for therapeutic feeding. In order to prevent misuse of dried milk it should be pre-mixed with a cereal flour before being distributed to feeding centers. If this cannot be done the dried milk should be mixed into cereal flours or porridges and stews before or during cooking. For take-home distribution. Dried milk should be pre-mixed with cereal flour before distribution to families and if possible before being given to the clinic or feeding centers. The only exception to this is when milk is an essential item of the traditional diet (e.g., of pastoralists) and can be used safely (e.g., soured).
(Source: UNHCR, 1990 in FAO, 1993a)

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Rations should provide approximately 55 percent of young child energy requirements and 30 percent of energy requirements for pregnant and lactating women. 8 to 12 percent of energy should come from protein. 20 to 25 percent of energy should come from fat. If possible, the ration should supply 100 percent of recommended requirements for vitamin A and iron. See Table 5-7 for illustrations of the recommended guidelines. Annex E, Tables E-1 to E-4 give sample ration recipes for general supplementary feeding of vulnerable mothers and young children, individual rations for school meals and snacks, an example of an individual ration for a pre-

Table 5-7: Suggested Amounts of Energy in Food Rations for Vulnerable Groups and Pre-Primary and Primary Schoolchildren
Mean Individual Energy Needs per Day (kcal) Vulnerable groups Children (6 to 60 months) Pregnant/lactating women Pre-primary school feeding Children (3 to 6 years) Primary school feeding Children (5 to 12 years) 1400 2600 1700 Type of Distribution Take-home Take-home On-site meal Supplied by Ration % of Needs 55 30 55 Amount (kcal) 800 800 900

1900

On-site: Meal Snack Meal + snack

55 2025 60

1000 400500 1100

(FAO, 1993a)

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primary schoolchild, and a porridge recipe for supplementation of younger children. Take-home rations Foods suitable for use as take-home rations include locally available cereals, pulses, and fats that are easy to distribute through facilities such as clinics and are easy for mothers to transport. Dried skim milk (see Box 5-1) and blended cereals (not available locally) are not recommended. Frequency of ration distribution depends on the objectives of the program (for example, to reduce prevalence of severe malnutrition or to increase attendance at monthly clinic sessions), and local conditions/ facilities. The weight of the ration and distance families must travel should also be considered. Duration of supplementation also depends on program objectives. For undernourished children, program eligibility is often determined by regaining lost weight, achieving and sustaining a percentage of their reference weight, and maintaining growth velocity. Pregnant women often receive rations from the time their pregnancy is confirmed through the first six months after delivery if they are lactating. On-site rations Food supplements prepared for consumption in a preschool or daycare setting, or for older school-age children during school hours contain a similar mix of cereals, pulses or legumes, and fat or oil. Complementary foods (vegetables, fruits, sugar, and spices) may possibly be provided by parents, the community, or grown in a school garden. To achieve maximum impact on attention spans and alertness of students, school snacks and meals should be given early in the day. Processed complementary (weaning) food production At the sixth month of life, breastmilk intake needs to be complemented by the introduction of nutrient-dense solid foods in order to meet the protein,

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energy, and other nutrient needs of the growing child. In many situations, adequately nutritious and developmentally appropriate complementary foods are difficult to obtain from the family foods available in the home, and processed complementary foods (particularly in the first months after beginning mixed feeding) may be advantageous. Some countries (e.g., Guatemala, Ethiopia) produce their own complementary foods based on locally grown foods and market them at relatively low prices. These may vary from a mix of a local cereal with the addition of a vegetable protein concentrate to a mix of a cereal, legume, and skimmed milk powder. Other animal products, fats, and sugars may be added to increase protein and energy density. Frequently, fats and oils are added only at the time of preparation because of storage/shelf life issues. Vitamin and mineral premixes are usually added during production, and some processed foods add a small amount of germinated cereal grain powder. The cereal powder contains the enzyme amylase in order to reduce the water content while increasing liquidity of the food. This in turn increases the nutrient density of the resulting complementary food (see footnote 5 in this chapter). Community-based production of complementary foods is another option for programs to consider. The Bank has experience with small-scale production in a number of regions using donated foods as well as locally available ingredients (e.g., ICDS in India, Sri Lanka Poverty Project). In all cases, it is important to follow internationally accepted food standards when developing recipes and production guidelines for processed complementary foods. The Codex Alimentarius is the international body responsible for the execution of the Joint FAO/WHO Food Standards Program, and as such, publishes food standards and codes of hygienic practice in relation to processed food production.8 Annex F contains the most recent (1994) standards for processed cereal-based foods for infants and

8. The Codex Alimentarius is available from the World Bank Sectoral Library or the Food and Agriculture Organization.

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children, the advisory lists of mineral salts and vitamin compounds for use in foods for infants and children, and the recommended international code of hygienic practice for food for infants and children. Information needs Those in charge of planning for project components addressing infant and young child feeding issues need to supervise data collection for problem identification, project planning, and monitoring and evaluation activities. Table 5-8 provides a list of the types of information of interest, possible indicators, and data collection methods for the various issues. An additional tool for task managers is the series of tables found in Annex E (Boxes E1 to E4) . These contain a detailed listing of the key practices and beliefs related to young feeding. The project preparation process will ideally include research to fill in the blanks for these matrices. Much of the information will be obtained through qualitative research methods that have been refined by professionals working in social marketing. Nutrition Communication (Toolkit #9), covers formative and other types of qualitative research methods such as in-depth focus group discussions with small (non-representative) samples of a population.

Nutrition in the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) program

IMCI is an integrated approach to the assessment, classification, treatment, and counseling of sick children and their caretakers. It prompts health workers to take the opportunity (the visit of a sick child) to counsel her family on common and recurring health and nutrition problems or concerns, while also addressing the problem at hand. New integrated treatment guidelines for malnutrition (also ARI, diarrhea, malaria, and measles) provide the basis for improved quality of care and essential child health services.

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Within the IMCI protocol, all children under 5 years of age are assessed for low weight-for-age and anemia. Feeding practices are assessed for all children 2 years and younger and those children between 2 and 5 who are underweight. Healthworkers are taught to counsel mothers about feeding behaviors, tailoring their advice to the individual household situation. Severely malnourished children who are not able to eat or who have serious infections are referred for medical intervention. Counseling guides and food boxes (a protocol for counseling families on infant and young child feeding) are adapted for each locality (see Figure E-1, Annex E for an example). Initial experiences with pilot tests of the nutrition portion of the IMCI protocol indicate that key feeding problems at various ages are similar, but recommendations on duration of exclusive breastfeeding and ingredients of complementary foods vary by region or country. The adaptation process for the food box and counseling messages utilizes the Trials of Improved Practices (TIP) methodology.9 Qualitative studies about local feeding practices, constraints to and motivations for behavior change, as well as information about environmental determinants of malnutrition (e.g., poor water and sanitation, high rates of infectious disease) lay the foundation for more realistic recommendations for feeding behavior strategies. Healthworkers work with families to adapt the IMCI feeding box and counseling dialogues to best fit the local community conditions.

9. For specific guidelines on how to plan, implement, and analyze TIPs, see Dickin, et al., 1997. The advantages of TIPs as a methodology to test program recommendations about feeding practices include direct interaction with mothers (and other caregivers) to elicit their current beliefs and practices, partnership in the process of determining which behaviors should and can be changed, choices about the change options, and follow-up consultation with caregivers to identify which behaviors changed and why.

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Table 5-8: Infant and Young Child Feeding: Information Needs for Program Planing, Monitoring, and Evaluation
Information Nutrition and health status: maternal/child Possible Indicators Clinical signs of malnutrition (nightblindness, conjunctival pallor, edema, etc.) Wasting, stunting, underweight Low birth weight Mid-upper arm circumference Infant and under-five mortality Frequency/type of child morbidity Food eaten for breakfast Time breakfast is eaten Foods brought to/purchased at school Teachers opinions Distance walked to school Availability of food at/near school; cost Rates of attendance at clinics, family planning services Rates of school and childcare center enrollment, attendance, and drop-out Distance from facilities to households Costs (time, money) Food preferences and taboos Feeding patterns of young children: breast/bottle feeding, timing of introduction of complementary foods, type of foods, frequency of feeding Eating patterns of women and adolescent girls (especially when pregnant/lactating) Feeding patterns of preschool/ school age children Data Collection Methods Physical examination Biochemical analyses Anthropometric assessment Family vaccination/health records Vital statistics registry Hospital/clinic/health center records Childrens dietary assessment survey: 24-hr. recall, food frequency questionnaires, food records In-depth interviews Observation Market surveys

Prevalence of preschool/school age children with short-term hunger

Utilization of health and social services

Clinic records, MOH records School records, MOE records In-depth interviews, observation Surveys

Feeding practices

Focus group discussions, in-depth interviews Dietary assessments including 24-hr. recall, food frequency questionnaires, analysis of dietary nutrient content Observation Surveys

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Information Feeding practices (continued)

Possible Indicators

Data Collection Methods

Food preparation methods Facilities for storing and preparing food Feeding utensils: type (bottles, cup/ spoon, hands), hygiene Water supply: distance, quality Fuel: type, source, cost Toilet/latrine: location, type, condition Household income Families eat < two meals/day Self-reported hunger after meals/ shortage of food Families living mainly on wild foods Young child meals contain little/ no fat High prices for staple foods or wide price fluctuations Families eating next years seeds Age of mother/other caregivers Parents/caregivers years of schooling Evidence of maternal depression Active infant/child feeding style Womens work-loads Family size and birth spacing Nearest market Frequency market open Prices of basic staples at market Amount, type of foods available at homestead Water board, local public health agency surveys Community surveys

Environmental constraints

Economic constraints; evidence of household food insecurity

Household income/ expenditure surveys Other surveys In-depth interviews, focus group discussions Market surveys Agricultural surveys CPI vs. minimum wage

Caregiver(s) attributes

Clinic records In-depth interviews Observation

Food availability

Observation Recall

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The Nutrition Minimum Package

Another approach to thinking about appropriate interventions for nutrition programs is the BASICS projects Nutrition Minimum Package of nutrition behaviors and supporting interventions and strategies. Six basic nutrition behaviors (see Box 5-2 below) are identified as fundamental to most community-based nutrition intervention program. By improving household behaviors, community supports and facility-based services, the minimum package can be achieved and sustained.

Box 5-2: Minimum Package of Nutrition Behaviors

1. For infants: Breastfeed exclusively for 6 months. 2. For infants and children: From about 6 months, provide appropriate complementary feeding and continue breastfeeding until 24 months. 3. For women, infants, and children: Consume vitamin A-rich foods and/or take vitamin A supplements. 4. For all sick children: Administer appropriate nutritional management: Continue feeding and increase fluids during illness Increase feeding after illness Give two doses of vitamin A to measles cases 5. For all pregnant women: Take iron/folate tablets. 6. For all families: Use iodized salt regularly.
(Sanghvi and Murray, 1999)