POLICY BRIEF

Infant and Young Child Feeding Practices IN , SOUTH WOLLO, AMHARA,

Information about current health and nutrition HIGHLIGHTS practices at the community level is essential for • Malnutrition among children in Tehuledere is high. understanding where problems lie and making decisions about what steps can be taken to Stunting is especially serious, affecting 26 percent of support improvements. This brief provides children younger than 2 years. summary information on infant and young child • Infant and young child feeding is suboptimal. While most feeding (IYCF) practices in Tehuledere, a woreda children (75 percent) start consuming foods in addition (district) in of , to breastmilk at 6–8 months of age, their diets are not Ethiopia. The data were gathered during a recent household survey conducted in 12 woredas in sufficiently diverse. The World Health Organization South Wollo, where efforts are under way by (WHO) recommends a diet that includes foods from the Alive & Thrive initiative, in partnership with four or more of the recommended food groups.3 In Concern Worldwide, to improve IYCF practices. Tehuledere, on average, children eat from only 1.8 food groups per day, and only 6 percent of children receive The data focus on the underlying and immediate foods from at least four of the recommended groups. In causes of malnutrition in the first 1,000 days particular, consumption of foods that contain sufficient of life—conception to 2 years of age—and are intended for use by woreda-level decisionmakers iron (meat or iron-fortified foods) is low. (administrators, nutrition officers, health • The diets of mothers/caregivers in Tehuledere also are extension officers, agriculture officers and not sufficiently diverse: only 26 percent eat foods from others) who can contribute to positive changes. four or more of the recommended food groups. They are meant to serve as a basis for designing action plans at the woreda level and to support • Home visits by Health Extension Workers (HEWs), the goals of the National Nutrition Programme’s Health Development Army (HDA) volunteers and other “Lifecycle Approach,” which emphasizes the first frontline workers are not adequate. In the three months 1,000 days.1 preceding the survey, only 22 percent of households POPULATION OF TEHULEDERE2 received a visit by a HEW and only 5 percent were Women: 62,971 visited by a HDA volunteer. Further, information Men: 71,353 Total: 134,324 provided during the visits lacked comprehensive messages on IYCF practices.

www.aliveandthrive.org JUNE 2015 A total of 3,583 mothers/caregivers of children aged 0–23 months participated in the survey. Among the sample of KEY RECOMMENDATIONS: children, 54 percent were boys and 46 percent were girls. • To reduce stunting in Tehuledere, the diets of Of these, 42 percent were 0–5 months old and 58 percent children younger than 2 years should be improved were 6–23 months old. to include more diversity. Children should consume Of the households surveyed, 29 percent reported being foods from at least four of the WHO-recommended either a current or former member of PSNP and 7 percent food groups, including a serving of meat, milk were members of the Household Asset Building Programme, or eggs. another food security program of the Ethiopian government. • Visits by HEWs and HDA volunteers should be more frequent and include counseling on SURVEY FINDINGS LEVELS OF HOUSEHOLD FOOD SECURITY exclusive breastfeeding, the timely introduction of In Tehuledere, approximately 36 percent of households complementary foods and specific foods to were identified as having secure access to food; 18 give to children older than 6 months in addition percent experienced mild food insecurity; 40 percent to breastmilk. experienced moderate insecurity; and 6 percent were severely food insecure.

NUTRITIONAL STATUS OF CHILDREN YOUNGER Why are the first 1,000 days important? THAN 2 YEARS Investments in good nutrition during the first 1,000 days of Stunting rates of children Figure 1: Prevalence of stunting by age group a child’s life contribute to his or her long-term health and younger than 2 years in wellbeing, and can also benefit future generations. Tehuledere were high (26 ›‹š Stunting percent), as at the national Underweight The biggest window of opportunity for preventing level (29 percent). Across Wasting ‡‘š undernutrition in the first 1,000 days of life is the period all woredas, stunting rates ‡Œš when a child consumes foods in addition to breastmilk started increasing at 6 ƒˆš ƒ„š ƒ„š Medium Maximum (6–23 months of age). A large proportion of stunting in months of age and reached ‘š ’š ˆš low-income countries occurs during this critical period.3 a high of 45 percent among Cereals ’‡š Cereals ’Œš children aged 12–23 months ŒŽ‹ mo ˆŽƒƒ mo ƒ‡Ž‡„ mo Legumes Legumes If children in Tehuledere eat better, they will grow better— (Figure 1). Stunting is caused ›„š „‹š both physically and mentally. This will improve their learning by a combination of factors, including long-term insufficient Milk and milk products ‡Œš Milk and milk products ‡‡š capacity, as well as their employment opportunities later in food intake, poor IYCF practices and frequent infections Meat ˆš Meat ‡š life. Girls will also grow into women who are better prepared early in life. Eggs ‹š Eggs ˆš to bring healthy infants into the world. Vit A rich fruits and vegetables ƒ‡š Vit A rich fruits and vegetables ‘š INITIATION OF BREASTFEEDING Other fruits and vegetables ƒŒš Other fruits and vegetables ƒ„š Initiation of breastfeeding within the first hour after birth BACKGROUND 0 20 40 60 80 100 0 20 40 60 80 100 The data included in this brief were collected as part of a can help prevent neonatal death, especially in preterm and household survey conducted in October and November low-birthweight infants. Colostrum, the sticky, yellow-white of 2014 by Addis Ababa University. They will provide a early milk, rich in antibodies, vitamin A and otherStrachy protective staple foods ƒŒŒš Strachy staple foods ƒŒŒš baseline for a comparative evaluation of two intervention factors, has been called baby’s first immunization. InfantsLegumes ’‡š Legumes ’ƒš “›š “‡š should be given no prelacteal feedsi such as water, otherNuts and seeds Nuts and seeds packages designed to integrate IYCF activities into Ethiopia’s Dairy ‡Œš Dairy ƒ›š Productive Safety Net Programme (PSNP), which is “aimed liquids or ritual foods. Meat ‹š Meat “š at enabling the rural poor facing chronic food insecurity to Eggs ‹š Eggs ›š In Tehuledere, only 69 percent of womenVitamin surveyed A rich dark saidleafy vegetables ƒƒš Vitamin A rich dark leafy vegetables ‡›š resist shocks, create assets and become food self-sufficient Other Vit A rich fruits and vegetables “š Other Vit A rich fruits and vegetables “š through the provision of food and/or cash transfers.”4 they had initiated breastfeeding of their youngest infantOther vegetables “Œš Other vegetables ““š within the first hour of birth and 81 percent reported thatOther fruits ‘š Other fruits „š 0 20 40 60 80 100 0 20 40 60 80 100 The survey was carried out in 72 kebeles (wards or they had given their baby colostrum. In addition, 24 percent neighborhood associations) randomly selected from 12 of infants had received prelacteal feeds. Sugar/glucoseMaximum ^ Medium ^ woredas: Albuko, Ambasel, Borena, , , Mahal water or raw butter was given most frequently. 100 100 Saint, Mekedela, Saint Ajibar, Tehuledere, , Wogedi

i and Worebabo. Foods given to newborns before breastfeeding has been established. 80 80

60 60 2 40 40

20 20

0 0

Dairy MeatEggs Meat Eggs Cereals Legumes Legumes Other fruits Nuts and seeds Other vegetables Strachy staple foods Milk and milk products

Other fruits and vegetables $ Vit A rich fruits and vegetables Vitamin A rich dark leafy vegetables BF = breastfeeding Other Vit A rich fruits and vegetables CF = complementary feeding 68 68 $ ITN = insecticide treated nets Amhara Amhara National National 49 ‹Œ 49 ‹Œ $ 39 37 39 37 5 $ ‡ˆ ‡ˆ

ƒ„ ƒ„ 9 9 6 4 6 4

BF CF ery SH oid eria ITN Zinc cine A cine ŒŽ‹ ˆŽ‘ ’Žƒƒ ƒ‡Žƒ“ ƒ‘Ž‡„ ŒŽ‹ ˆŽ‘ ’Žƒƒ ƒ‡Žƒ“ ƒ‘Ž‡„ g India c ox c thiopia Ni a W amin A a mo mo mo mo mo mo mo mo mo mo E angladesh an dliv Vit B Hib v anus t Cle et asles v T Me Source: Hoddinott et al EXCLUSIVE BREASTFEEDING Many foods were introduced to children very late. This was especially critical›‹š for milk, meat, eggs and legumes. Milk Breastmilk contains all the nutrients that a baby needs for Stunting the first six months of life. WHO recommends exclusive (otherUnderweight than breastmilk) and eggs were generally introduced Wasting breastfeeding—with no other foods or fluids including at 14 months. Green‡‘š leafy vegetables, fruits and legumes were introduced at 17 months on average and meat as late water—until a baby is six months of age. At the time of the ‡Œš as 18 months.ƒˆš survey, a significant proportion (83 percent) of babies 0-5 ƒ„š ƒ„š Medium Maximum months of age were being exclusively breastfed. ‘š ’š ˆš DIETS OF MOTHERS Cereals ’‡š Cereals ’Œš INTRODUCTION OF COMPLEMENTARY FOODS AT OnlyŒŽ‹ mo 26 percentˆŽƒƒ mo ƒ‡Ž‡„ of mothers mo reported having consumed Legumes ›„š Legumes „‹š 6 MONTHS at least one serving from at least four of the WHO- Milk and milk products ‡Œš Milk and milk products ‡‡š A large proportion of child stunting occurs within 6–23 recommended food groups the previous day. Very few Meat ˆš Meat ‡š months of age. Appropriate feeding promotes growth and mothers reported having eaten animal products like milk, prevents stunting during this time, and the timing as well meat or eggs (Figure 3). Consumption of vitaminEggs A rich‹š fruits Eggs ˆš as the quality of the foods is crucial. More diverse diets are and vegetables like pumpkin,Vit A richcarrots fruits andand vegetables kale was alsoƒ‡š very Vit A rich fruits and vegetables ‘š associated with lower stunting rates.2 low. Mothers consumed moreOther legumes fruits and than vegetables children, however.ƒŒš Other fruits and vegetables ƒ„š 0 20 40 60 80 100 0 20 40 60 80 100 Figure 3: Food groups consumed by mothers in the day In Tehuledere, introduction of foods in addition to preceding the survey (at least one serving) N=1,198 breastmilk appeared timely for most children, with 75 ƒŒŒš ƒŒŒš percent of caregivers reporting they began to feed solid Strachy staple foods Strachy staple foods Legumes ’‡š Legumes ’ƒš and semisolid foods when a child was 6–8 months of age. Nuts and seeds “›š Nuts and seeds “‡š For 25 percent of children, however, solid foods were Dairy ‡Œš Dairy ƒ›š introduced later than 6–8 months. Meat ‹š Meat “š Eggs ‹š Eggs ›š Vitamin A rich dark leafy vegetables ƒƒš Vitamin A rich dark leafy vegetables ‡›š In addition, foods introduced to young children were not Other Vit A rich fruits and vegetables “š Other Vit A rich fruits and vegetables “š sufficiently varied. According to WHO, children should be Other vegetables “Œš Other vegetables ““š Other fruits ‘š Other fruits „š fed from at least four of the recommended food groups 0 20 40 60 80 100 0 20 40 60 80 100 each day: grains, roots and tubers; legumes and nuts; dairy products; flesh foods (meat, fish, poultry, liver or other HANDWASHING PRACTICESMaximum ^ Medium ^ organ meats); eggs; vitamin A rich fruits and vegetables; Handwashing with soap and water before preparing or giving a child food and after using a latrine or cleaning a child can 100 100 and other fruits and vegetables.5

prevent infections that can lead to poor appetite, malnutri- 80 80 tion and death. Each year, more than two million children The survey found that only 6 percent of children in worldwide younger than 5 years die from diarrhea and pneu- 60 60 Tehuledere were receiving foods from the recommended monia.6 Addressing the main barriers to proper handwashing four or more food groups each day; on average, eating from 40 40 is a lifesaving and cost-effective intervention. Handwashing only 1.8 of these groups (Figure 2). In particular, high- at appropriate times can help prevent the spread of common 20 20 protein foods like meat, milk products and eggs were given childhood illnesses and reduce stunting and wasting. once a day to fewer than 20 percent of children. And only 0 0

4 percent of children in Tehuledere, versus 12 percent for Dairy MeatEggs Meat Eggs In Tehuledere, 86 percent of caregivers reported that they Cereals the country as a whole, were receiving foods that contain Legumes Legumes ›‹š Other fruits Stunting washed their hands before preparing food, but only 63 per- Nuts and seeds sufficient amounts of iron (meat or iron-fortified foods). Other vegetables Underweight Strachy staple foods cent reported using soap. In addition, only 38 percent said Milk and milk products Wasting ‡‘š they washed their hands before feeding a child and only 21 Other fruits and vegetables $ Vit A rich fruits and vegetables percent after attending to a child who had defecated. ‡Œš Vitamin A rich dark leafy vegetables Figure 2: Food groups consumed (on the day Other Vit A rich fruits and vegetables ƒˆš BF = breastfeeding ƒ„š ƒ„š Medium preceding the survey)Maximum by children 6–23 months old CF = complementary feeding 68 68 ’š in Tehuladere (N=696) $ ITN = insecticide treated nets Amhara ‘š WATER AND SANITATION Amhara ˆš National National A growing body of evidence links open defecation in 49 ‹Œ 49 ‹Œ Cereals ’‡š Cereals ’Œš $ ŒŽ‹ mo ˆŽƒƒ mo ƒ‡Ž‡„ mo communities to poor child health. Diarrhea resulting from 39 37 39 37 Legumes ›„š Legumes „‹š 5 $ contact with feces in the environment is a major problem in ‡ˆ ‡ˆ Milk and milk products Milk and milk products ‡Œš ‡‡š these communities, leading to a vicious cycle of illness, poor ƒ„ ƒ„ Meat ˆš Meat ‡š 9 9 absorption of nutrients and poor nutrition. Further, after 6 4 6 4 Eggs ‹š Eggs ˆš repeated exposure to feces over time, a child’s intestines BF CF ery SH oid eria ITN Zinc cine A cine ŒŽ‹ ˆŽ‘ ’Žƒƒ ƒ‡Žƒ“ ƒ‘Ž‡„ ŒŽ‹ ˆŽ‘ ’Žƒƒ ƒ‡Žƒ“ ƒ‘Ž‡„ Vit A rich fruits and vegetables ƒ‡š Vit A rich fruits and vegetables ‘š g India c ox c thiopia Ni a W amin A a mo mo mo mo mo mo mo mo mo mo becomeE unable to absorb nutrients properly even when angladesh an dliv Vit B Hib v anus t Other fruits and vegetables ƒŒš Other fruits and vegetables ƒ„š diarrhea is not present. This condition is calledCle chronice t asles v T Me 0 20 40 60 80 100 0 20 40 60 80 100 7 environmentalSource: Hoddinott enteropathy et al and also undermines health.

3 Strachy staple foods ƒŒŒš Strachy staple foods ƒŒŒš Legumes ’‡š Legumes ’ƒš Nuts and seeds “›š Nuts and seeds “‡š Dairy ‡Œš Dairy ƒ›š Meat ‹š Meat “š Eggs ‹š Eggs ›š Vitamin A rich dark leafy vegetables ƒƒš Vitamin A rich dark leafy vegetables ‡›š Other Vit A rich fruits and vegetables “š Other Vit A rich fruits and vegetables “š Other vegetables “Œš Other vegetables ““š Other fruits ‘š Other fruits „š 0 20 40 60 80 100 0 20 40 60 80 100

Maximum ^ Medium ^

100 100

80 80

60 60

40 40

20 20

0 0

Dairy MeatEggs Meat Eggs Cereals Legumes Legumes Other fruits Nuts and seeds Other vegetables Strachy staple foods Milk and milk products

Other fruits and vegetables $ Vit A rich fruits and vegetables Vitamin A rich dark leafy vegetables BF = breastfeeding Other Vit A rich fruits and vegetables CF = complementary feeding 68 68 $ ITN = insecticide treated nets Amhara Amhara National National 49 ‹Œ 49 ‹Œ $ 39 37 39 37 5 $ ‡ˆ ‡ˆ

ƒ„ ƒ„ 9 9 6 4 6 4

BF CF ery SH oid eria ITN Zinc cine A cine ŒŽ‹ ˆŽ‘ ’Žƒƒ ƒ‡Žƒ“ ƒ‘Ž‡„ ŒŽ‹ ˆŽ‘ ’Žƒƒ ƒ‡Žƒ“ ƒ‘Ž‡„ g India c ox c thiopia Ni a W amin A a mo mo mo mo mo mo mo mo mo mo E angladesh an dliv Vit B Hib v anus t Cle et asles v T Me Source: Hoddinott et al In Tehuledere, 37 percent of households reported that they had no access to a IMPROVING THE DIETS toilet facility. About 70 percent of households reported having both a traditional OF CHILDREN WILL HELP pit latrine and an improved source of water for drinking and cooking purposes. REDUCE STUNTING IN MATERNAL KNOWLEDGE ABOUT IYCF PRACTICES TEHULEDERE—MAKING Almost 80 percent of mothers in Tehuledere had good overall knowledge about CHILDREN MORE breastfeeding initiation and the importance of exclusive breastfeeding for the first PRODUCTIVE MEMBERS six months, as well as when to introduce solid or semisolid foods into an infant’s diet. OF SOCIETY OVER THE Fewer mothers (45 percent) knew that no water should be given to an infant LONG TERM. before 6 months of age, even in very hot weather. Only 30 percent of mothers knew that they could continue breastfeeding if they became pregnant again. Hardly any mothers (2.5 percent) knew that they could express milk for their REFERENCES babies if they had to be separated from them. 1 Government of the Federal Democratic Republic of Ethiopia. National Nutrition Programme June 2013–June 2015. 2013. Available from: http://www.unicef.org/ Only 26 percent of women knew that traditional gruels often given as first ethiopia/National_Nutrition_Programme.pdf. foods are too thin to satisfy the nutrient needs of an infant. 2 Central Statistical Agency of Ethiopia [Internet]. Available from: http://www.csa.gov.et/. 3 International Food Policy Research Institute (IFPRI). Global Nutrition Report 2014: Actions and Accountability to SUPPORT AND INFORMATION FROM HEWS AND THE HDA Accelerate the World’s Progress on Nutrition. Washington, Only about 22 percent of households reported having had a visit from a HEW DC: IFPRI; 2014. 4 World Food Programme (WFP). Ethiopia: Productive in the past three months. Even fewer (5 percent) had been visited by a HDA Safety Net Programme (PSNP). Addis Ababa: WFP; September 2012. volunteer. Only about one-third of visits were reported to have included 5 World Health Organization (WHO) Nutrition Landscape counseling on exclusive breastfeeding for six months and introduction of Information System [Internet]. Geneva: WHO; 2015. Available from: http://apps.who.int/nutrition/landscape/ complementary foods. No mother reported a visit in which she was counseled help.aspx?menu=0&helpid=394. on all of the relevant IYCF messages. 6 United Nations Children’s Fund (UNICEF). Pneumonia and Diarrhoea: Tackling the Deadliest Diseases for the World’s Poorest Children. New York: UNICEF; 2012. 7 Humphrey JH. Child undernutrition, tropical enteropathy, HOW TO MAINTAIN BREASTFEEDING RATES AND IMPROVE THE toilets, and handwashing. Lancet. 2009 Sep DIETS OF CHILDREN IN TEHULEDERE 19;374(9694):1032-5. • Good progress has been made in improving early initiation of breastfeeding. However, the dangerous practice of giving water to a child before 6 months of age is still very common. HEWs and the HDA should improve support to mothers in Tehuledere through individual counseling STAY CONNECTED and mother-to-mother support groups. WITH ALIVE & THRIVE • HEWs and HDA volunteers should remind families and communities about the importance of giving young children a varied diet. Children should E-mail: [email protected] receive meat, eggs and legumes every day starting at around 6 months of age. Children in Tehuledere need to eat a more varied diet, including Twitter: @aliveandthrive at least one serving from at least four of the WHO-recommended food groups every day. Blog: www.lessguess.wordpress.com • Visits by HEWs and HDA volunteers should emphasize the importance of washing hands before preparing and giving food to infants and young Facebook: children and after defecation or cleaning a child. www.facebook.com/fhi360. aliveandthrive • HEWs and HDA volunteers in Tehuledere should visit with individual mothers and their communities at least once every two months. Youtube: www.youtube.com/aliveandthrive • Complementary feeding demonstrations should be organized in communities to help mothers learn how to prepare healthier food for their children. www.aliveandthrive.org

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