Dietary Practices of Lactating Women and Nutritional Status of Children in Baglung District, Nepal

Acknowledgements: We want to forward our special thanks to Institutional Review Committee (IRC) of Pokhara University Research Centre for providing ethical clearance for the research. Most importantly, our sincere gratitude goes to all the participants for providing their valuable time and information without whom this study would not be completed. Funding: Nil Conflict of Interest: None Permission from IRB: Yes Dietary Practices of Lactating Women and Nutritional Status of Children in Baglung District, Nepal


Introduction
L actation is defi ned as the period of the new-born infant's life in which breast-milk is the primary source of nourishment. Breast-milk is the ideal food for new-born infants and studies shows that breast-fed infants have fewer problems with infectious and non-infectious diseases, and experience milder cases of respiratory and ear infections as well as diarrhoea than non-breast-fed babies 1 .
Both mother and child participate in the act of nursing, and consequently breast-feeding success depends on the two of them 1 . The nursing mother fi rst needs to focus on meeting her nutritional requirements. The energy required to produce 1 litre of milk is estimated around 700 kcal and so recommendations include increasing energy intake above the pre-pregnant requirements by 500 kcal day 1 . According to the essential nutrition action (ENA), taking at least two additional meals per day during lactation is recommended for all lactating women 2 .
During the fi rst six months after delivery, the baby is fed only on breast milk, and the baby depends on the mother for all nutrient requirements. Eating a healthy diet while breastfeeding is important because what mother eats determines the energy, protein, nutrient and vitamin content of breast milk. So food should be selected and prepared properly 3 .
Around the age of six months, an infant's need for energy and nutrients starts to exceed what is provided by breast milk and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods 4 . IYCF practices guidelines promoted by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend feeding an average healthy child in the following way: continued breast-feeding, solid/semi-solid foods 2-3 times for infants 6-9 months old and 3-4 times for infants 9-24 months old, with an additional snack being off ered 1-2 times per day. The minimum IYCF practices for children 6-23 months are defi ned as continued breastfeeding, feeding at least the minimum number of times per day, and feeding from minimum number of food groups per day 5 .The criteria for non-breastfed children include feeding substitutes of breast milk (infant formula, powdered or fresh animal milk, cheese, yogurt and other milk products) 5 .
As recommended by WHO, evaluation of nutritional status is based on a comparison of three indices for the children with indices reported for a reference population of well-nourished children (WHO Multicentre Growth Reference Study Group 2006). The three indices (height-for-age, weight-for-height, and weight for-age) are expressed as standard deviation units from the median for the reference group. Children who fall below minus two standard deviations (-2 SD) from the median of the reference population are regarded as moderately malnourished, while those who fall below minus three standard deviations (-3 SD) from the reference population median are considered severely malnourished. Marked diff erences, especially with regard to height-for-age and weight-for-age, are often seen between diff erent subgroups of children within a country 6 .
The aim of this study was to fi nd the dietary practices of lactating women and nutritional status of their children.

Material and Methods
A cross sectional study was conducted in Baglung district, Nepal. The sample size was determined by assuming national prevalence of children feed with minimum acceptable diet that is 35% with 5% precision at 95% confi dence interval. Sample size was 343 of lactating women and their children. Out of 343 children, underweight was measured to all children while stunting and wasting were calculated to children whose age was above six months (180).
In Baglung district, listed all four municipalities and six rural municipalities then one municipality and one rural municipality were randomly selected from the list for the study area. Baglung municipality and Kathe khola rural municipality were selected for study areas. After that all households which had at least one lactating woman having less than two years child were selected and listed from every ward of selected municipality and rural municipality. Researcher went to the centre of ward, spin the pen and the direction as indicated by the head of pen was chosen then researcher moved round and round in the chosen direction until researcher get 16 samples from each ward.
Inclusion of participant in the study was determined by mothers consent and the age of child was being between 0-23 months. After taking verbal and written informed consent of lactating woman of child then data were collected regarding her dietary practice, child feeding practices and their nutritional status trough using pre-designed, pre-tested questionnaire in Pokhara Lekhnath Municipality, Nepal.
Tools for data collection were interview schedule, Salter scale for weight measurement, Stadio meter for height measurement and fl ash cards, sample plastic fruits and bowls. Interview schedule was prepared by extensive literature review. The schedule consisted of four parts: part I socio-demographic information, part II mothers dietary pattern, part III child feeding practices, and part IV tapped nutritional status of child.
For determining IYCF practices; guidelines promoted by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend feeding an average healthy child in the following way was adapted: continued breast-feeding, solid/semi-solid foods 2-3 times for infants 6-9 months old and 3-4 times for infants 9-24 months old, with an additional snack being off ered 1-2 times per day and feeding from minimum number of food group (<4) per day.
As recommended by WHO, evaluation of nutritional status is based on a comparison of three indices for the children with indices reported for a reference population of well-nourished children (WHO Multicentre Growth Reference Study Group 2006). The three indices (height-for-age, weight-for-height, and weight forage) are expressed as standard deviation units from the median for the reference group. Children who fall below minus two standard deviations (-2 SD) from the median of the reference population are regarded as moderately malnourished, while those who fall below minus three standard deviations (-3 SD) from the reference population median are considered severely malnourished.
The size of dishes used to measure the amount of food was of 250 ml, which was equivalent to a standard cup size. Through this reference, the amount of food was converted into a standard serving size, and the daily energy intake was calculated by Nutrition facts 0.9.5.0 version and food tables.
Face to face interview was conducted among women to collect the data and anthropometric measurement was performed among the children. Data were entered in EPI-DATA version 3.1 and exported to Statistical Package for Social Sciences (SPSS version 17.0) for further analysis. Data analysis was done by standard statistical methods, percentage were calculated for descriptive statistics. Chi-square test of signifi cance was employed whenever required.
Ethical approval was taken from Pokhara University Research Center. The approval was taken from Baglung municipality and Kathe khola rural municipality of Baglung district before initiation of the study.

Results
In this study 7.9% of mothers were below 21 years, 87.2% were between 21-35 years and 5% were above 35 years age. Among the respondents by ethnicity 50.7% were upper caste group. Based on religion a majority of 90.7% were Hindu. Majority of respondents (63.3%) were from rural area. Nuclear family was more common than joint family (67.1% vs 32.9%). Nearly 12 % had not attended any formal schooling. Likewise more than half (56.0%) were involved in household work and around 16% were employed in government job, 14.3% do have their own business, and remaining 9.3%, 2.9%, 1.5% were involved in agriculture, labor work and others respectively. Monthly income of mother was classifi ed into 5 quintiles, in this study the proportion of lower quintile was relatively less while all other category of quintiles were almost equal proportion.
More than half (56.5%) of children were male and also 52.5% of them were above 6 months of age. Table 1 show that only 5.2% of mothers took 2 extra meals during the previous day and 31.8% have recommended energy intake. Table 2 depicts the 3 indicators considered in this study for determining the magnitude of appropriate breastfeeding practices. More than 90% of children were breastfeed feed within one hour of birth and 34.5% of infants aged 0-5 months were feed exclusively with breast milk. Table 3 represent the complementary feeding practice to 6-23 months children. 42.3% of breastfed infants 6-8 months of age received solid, semi-solid or soft foods for at least 2 times, 46.6% of breastfed children 9-23 months of age received solid for at least 3 times, 23.5% of non-breastfed children 6-23 months of age received for at least 4 times. 43.7% of children 6-23 month of age received foods from 4 or more food group and 15.6% of infants were bottle feed.
The WHO Classifi cation of Malnutrition in less than two years age group is depicted in Table 4. Age specifi c values of height, weight are shown. The rate of stunting, wasting and under-weight was 22.2%, 10% and 9.3% respectively. Table 5 represents daily energy intake of mothers. Only 31.8% of mother's energy intake was as recommended. Table 6 shows the factors association between nutritional status of children and dietary practices of mothers. In this study daily energy intake by mother was not associated with nutritional status of children. Table 7 shows the association between nutritional status of child and feeding practices to them. Stunting and wasting were signifi cantly associated with feeding practices whereas under-weight was not associated with feeding practices to children.
J. Nepal Paediatr. Soc.  Proportion of infants 0-6 months of age who are fed exclusively with breast milk 71(34.5%)  Children who had score from -2 SD to +2 SD median of the reference population are normal 140 (77.8%) Children who fall below -2 SD from the median of the reference population are malnourished 18 (10%) Children who had score from -2 SD to +2 SD median of the reference population are normal 162 (90%) Under-weight (n=343) Children who fall below -2 SD from the median of the reference population are malnourished 32 (9.3%) Normal Children who had score from -2 SD to +2 SD median of the reference population are normal 311 (90.7%)

Discussion
In this study it was found that majority of mothers were not taking additional two meals which consistent with the study in Ethiopia 2 . Likewise, energy intake of mothers was insuffi cient which agrees with similar studies 2,5,7 .
Findings of the current study shows that 91.8% of children were breastfeed within one hour of birth and these fi ndings are higher than the fi nding of similar study conducted in Nepal which shows rate of timely initiation of breastfeeding was 72.7%% 8,9,10 .
Globally, only about one-third of infants are fed breast milk exclusively for their fi rst 6 months 11 . In this study majority (34.5%) of children (6-24 months) were exclusively breastfeed for fi rst 6 months and this rate was higher than Eastern Europe/Commonwealth of Independent States (14%), and South Asia (36%), and similar to East Asia/Pacifi c regions (52%) 12 .
In this study 9.3% children between 6-23 months were fed using the bottle with nipple which was higher than fi nding of related studies conducted in Bangladesh (3.5%) 13 .
In this study dietary diversity (7 food groups) for children aged 6-23 months (food groups eaten <1 day) was assessed, and result presents that mean dietary diversity score was 1.44. In Similar review by Arimond and Marie T. Ruel on dietary diversity(7 food groups) for children aged 6-23 months (food groups eaten <3 day), revealed mean diversity score to be low in African ( 14 . In this study dietary diversity score was less than scores of African and Asian countries. Number of meals intake during breastfeeding was not signifi cantly associated with nutritional status of child. This study shows that daily energy intake was signifi cantly associated with mid upper arm circumference of child. Energy intake was not signifi cantly associated with wasting, stunting and underweight. A study conducted in Russia also suggests there are no evidence-based recommendations existing concerning the intake of dietary macronutrients of a lactating woman, which optimizes the physical development of a baby 15 . Poor infant and young child feeding (IYCF) practices are recognized as a significant contributor to under nutrition globally 16 .In present study complementary feeding practice to child was signifi cantly associated with wasting and stunting whereas weight for age and mid-upper arm circumference were not signifi cantly associated and this result was compared to reports of similar studies in Nepal and other countries. Many children in developing countries become stunted during infancy as a result of inappropriate weaning practices and poor diet. Various studies in developed and developing countries suggest that stunting is associated with complementary feeding practices 14,[17][18][19][20][21] . This study also found the similar result.
The result of this study also reveals that underweight was not signifi cantly associated with complementary feeding practices but a similar study by Kumar et al. observed improper complementary feeding was signifi cantly associated with underweight 22 .

Conclusion
Majority lactating women were not taking additional meals as per need during this period and their energy intake was not suffi cient. Nearly three-fourth children had not achieved satisfactory feeding practice. The rate of stunting, wasting and under-weight was high. Dietary J. Nepal Paediatr. Soc.
practice of mother was not signifi cantly associated with nutritional status of children. Complementary feeding practice to the children was associated with wasting and stunting status.

Recommendation
The awareness on nutritional requirement during lactation period should be focused and adequate message should be disseminated to lactating mothers and their family members in order to improve her dietary practices. Adequate nutritional food should be provided to lactating mother in order to meet high energy requirements during lactation. Mothers and primary feeder of children should be encouraged to feed children with diverse food groups and at regular interval. The focus on proper weaning practices to child should be focused in order to improve nutritional status of children.