The overall level of compliance with the WHO guidelines for complementary feeding was higher than that reported nationally (6). This was possibly due to the fact that the study was based in a tertiary level hospital in a middle-class urban area. The KDHS 2014 (6) indeed reported that children in rural areas were less likely to be fed appropriately than their urban counterparts. Regionally, caregivers in Nairobi had the highest rate of adherence to Infant and Young Child Feeding (IYCF) practices. An increase in mother’s education and increased household wealth were associated with more appropriate complementary feeding practices (6).
Age of the infant as well as caregiver’s education level were found to be significantly associated with compliance with WHO guidelines on multivariate logistic regression. This is similar to previous studies that have reported that education level of the caregiver is associated with both complementary feeding practices and nutritional outcomes. For instance, lower maternal education and lower household wealth index were found to be the most consistent factors influencing inappropriate CF practices in the South Asian region (14). In Kenya, significant differences between malnourished children and children with normal nutritional status in relation to the education levels of their mothers and their fathers have been reported (8). In that study, the child was more likely to be malnourished if he/she came from a family where both parents had low and no education.
Gender of the child, as it affects feeding practices, was also explored in the qualitative arm of this study. Caregivers narrated the myth that 'boys feed more than girls', although this did not influence their feeding choices. This is in contrast to a study by, Kimani-Murage et al (9) that found male gender was associated with earlier introduction of complementary feeds. The reason for this, though given anecdotally, was that boys did not seem to achieve satiety with breast milk alone. This fits into the aforementioned myth that boys have higher nutritional demands than girls.
Cultural beliefs concerning complementary feeding practices were varied as caregivers came from different cultural backgrounds. Prohibitions, though freely quoted by caregivers, were mostly ignored because respondents felt that they were outdated. This is in contrast to a study in South Africa which found strict adherence to cultural beliefs (15). This is likely because the South African study was conducted in a rural setting, as opposed to this study which was done in an urban setting. However, some caregivers conceded that their practice had been affected by culture, albeit subconsciously. For example, there was a tendency to overfeed with certain starches such as potatoes and pumpkins and a hesitance to introduce some animal proteins like eggs. A commonly held cultural belief was that eggs, if given early, would cause a delay in the child's speech. However, on correlation with the quantitative data, it was found that almost half of the caregivers had given eggs to their children in the twenty-four hours prior to the study. Many caregivers also reported that their culture advocated for early introduction of complementary feeds. This, again, was not reflected in actual practice as most caregivers reported introducing complementary feeds at six months.
Caregivers in this study had access to multiple sources of information regarding complimentary feeding. Majority of them still considered the paediatrician their primary source of information and listed previous experience, the internet, relatives and friends as other influencers. The internet, in particular, served to provide supplementary information as well as support since it allowed for connection with other caregivers. Most caregivers attended the six-month clinic and received some nutritional advice. However, the qualitative aspect of this study revealed that there was inconsistency in the information given. This is likely due to lack of standardised protocol for complementary feeding at the well-baby clinic. The time constraint of a busy clinic also posed a challenge to the successful delivery of nutritional advice. This calls for a multidisciplinary approach to the problem, for example, involving nurses and nutritionists. Caregivers also lacked in-depth understanding about the importance of various guidelines. All these factors led to a disparity between the level of knowledge and full compliance with the guidelines. These findings are similar to those of a study done at Mbagathi District Hospital, Nairobi, that found lack of consistency in information delivered to caregivers by health care workers which led to a disparity between knowledge and practice(7).
The internet as a source of information was frequently mentioned. A variety of sources ranging from scientific research papers to online interactive sites to popular social media platforms like Facebook were quoted. The internet was seen as an authority by some caregivers but others approached it with more caution and confirmed the information therein with their healthcare provider. Plantin et al (16) in their review found that majority of parents went online in search of information or support. An important reason for this was weakened social support from caregiver's relatives and friends. Professionals had responded to this interest by offering online information as well as support. Benefits such as increased access to resources, without an added cost implication, and the ability to meet the demand for information round the clock were cited.
We found that caregivers were least compliant to the guidelines on continued breastfeeding to the age of two years, with a compliance rate of 74%. Of the children still being breastfed, 65.9% were aged 9–12 months, 25.8% were 13–18 months while 8.3% were 19–24 months. This rate of continued breastfeeding is still higher than reported in middle income populations in high income countries. In Australia, for example, a cohort study found that 31.8% of women breastfed to 12 months and only 7.5% to 24 months (13).
An increase in the age of the infant in this study was associated with discontinuation of breastfeeding (P < 0.001). This is similar to a study done in Tanzania (17) where breast feeding rates were also reported to decrease with age. The two main reasons given for discontinuation were the child losing interest in breastfeeding and insufficient milk. This may be an indication of the need to continue lactation support beyond the immediate post-partum period and educate mothers on the importance of continued breastfeeding. Findings from the qualitative arm of this study underscored the role that lactation nurses played in encouraging mothers to continue breastfeeding. They followed mothers through phone calls and offered a holistic approach to lactation management, including addressing the psycho-social aspects.
Majority of the caregivers in this study were professionals who cited time as a major challenge for clinic attendance, which meant less contact time with the healthcare workers. Time constraints also affected the extent to which some caregivers were able to plan, prepare and feed their children. There was, however, no significant association between profession and compliance with the WHO feeding guidelines. This may be due to the fact that the study was done in a tertiary hospital based in an urban setting and most caregivers were professionals. Pelto et al reviewed case studies on improving feeding practices and found that time constrains was the most recurring theme. Caregivers often had competing demands on their time that created constraints on care-giving. This was true for both urban and rural settings, since most caregivers today must also engage in an income-generating activity. The time factor was found to affect the selection and preparation of foods, as well as feeding styles (18). The structure of the well-baby clinic and the protocol developed must bear these factors in mind, if it is to impact the feeding practices of caregivers in our setting.
Majority of respondents in this study afforded private healthcare, either as part of an insurance scheme or out-of-pocket. Resources, however, are finite and this meant that some items were out of reach. This was especially true for caregivers who had underweight or allergy-prone babies and needed special formulas. Some parents wanted to expose their children to a wider variety of foods but found the cost of items that are not locally produced prohibitive. Socioeconomic status was not studied in the quantitative aspect of this study but has been found to be significantly associated with adherence to guidelines and nutritional outcomes in previous studies (8).
Fear of allergies emerged as a factor affecting introduction of various foods by caregivers, particularly protein rich foods. In some cases, the fear was well founded because of past experiences while in others, the fear was founded on suspicion or a myth. In cases where certain foods were completely restricted, suitable alternatives were not always available. In other cases, the caregiver opted to delay introduction of certain foods that are commonly known to be allergenic. There is currently no guideline on when potentially allergenic foods should be introduced. However, a recent randomized trial found that peanut and egg allergy were less prevalent in an early introduction group of three months than in the standard introduction group of six months (19). While the recommendation is certainly not to introduce allergenic foods in the third month of life, the findings suggest that late introduction of allergenic foods may actually predispose young children to development of allergies. This issue therefore needs to be addressed during development of complementary feeding guidelines.
Caregivers who worked outside the home had to rely on others to assist in preparing meals and feeding of their children. Good support in these areas positively affected feeding practices, as has also been reported in previous studies. A Gambian study, for instance, found that the social support network of mothers affected adherence to the infant care guidelines. The husband was reported as the most important of these support systems (20).
Regarding health-worker support, caregivers emphasized the important role played by nurses in giving holistic support, especially during the initial lactation period. When it came to complementary feeding, however, nurses were the least reported as an information source. This may be due to the fact that there were only two dedicated lactation nurses who focused mostly on establishing and supporting the initial breastfeeding period. The same emphasis is, however, not made for complementary feeding or continued breastfeeding. Numerous studies have shown the important role that can be played by health workers in influencing caregivers' feeding practices. A randomized trial on the efficacy of breastfeeding support provided by trained clinicians, for instance, showed that there was an improvement in breastfeeding outcomes with the intervention of a routine, preventive, outpatient visit (21). More training and support of all cadres of healthcare workers is needed to achieve this.