Feeding practice and associated factors among infants and children with common childhood illness at Dabat Health and Demographic surveillance System site: A community based cross-sectional study

Background: Optimal feeding practices are recommended to improve nutritional status and prevent the common childhood illnesses. Studies on the feeding practice of children including meal frequency and dietary diversity are scarce in children with illness. Therefore, we aimed to assess feeding practice and its associated factors among children aged 6-59 months in Dabat Health and Demographic Surveillance System (HDSS) site, northwest Ethiopia. Methods : A community based cross-sectional study was conducted in Dabat HDSS site from February to June 2016 on 1,174 mother-child pairs. A multistage stratified sampling followed by a systematic random sampling technique was employed to select the study participants. A binary logistic regression model was fitted to identify factors associated with children’s feeding practice. A crude odds ratio and adjusted odds ratio with its 95% confidence intervals (CI) were calculated to see the strength of association and significance of the identified factors with feeding practices. Result: The overall prevalence of a minimum dietary diversity practice and a minimum meal frequency was 27 % (95%CI: 24.4, 29.7) and 83.7 %( 95%CI: 91.7, 86.0), respectively. Having antenatal care (ANC) service (AOR = 1.6; 95% CI: 1.18, 2.27) and institutional delivery (AOR = 2.6; 95% CI: 1.85, 3.55) increased odds of an adequate dietary diversity in children. On the contrary, the odds of practicing an adequate dietary diversity was lower among a household obtained food from home gardens (AOR = 0.4; 95% CI: 0.29, 0.52) and currently breast fed children (AOR = 0.6; 95% CI: 0.42, 0.78). The probability of having a minimum meal frequency was decreased among children in the first two years of age (AOR = 0.1; 95% CI: 0.06, 0.15), however increased in children who fed alone (AOR = 1.9; 95% CI: 1.29, 2.69). Conclusion: The proportion of children who received the minimum dietary diversity was low while the proportion of children who obtained minimum meal frequency was good. Providing a health and nutrition counseling on Infant and Young Child Feeding during maternal ANC services and delivery period are recommended


Background
Appropriate feeding practices during and after illness are important measures to meet nutritional requirements of infants and children [1]. These children, requires a variety of foods and energy-rich food groups in the diet to ensures an adequate intake of essential nutrients and for growth and development [2]. Achieving the minimum dietary diversity for children aged 6-59 months is critical as they require energy and nutrient-dense foods for their physical, mental growth and development [3].
The World Health Organization (WHO) develops a Guiding Principles for Complementary feeding of breastfed and non breastfed children of an optimal feeding practices during and after common childhood illnesses to prevent a rapid deterioration of nutritional status associated with illness/convalescence as part of the WHO-led Global Strategy for the Integrated Management of Childhood Illnesses [4,5].
Evidences indicate that, most under-nutrition in low and middle income countries occurs during young children as a result of suboptimal breastfeeding and complementary feeding practices [6,7]. More importantly, children's nutritional status can deteriorate rapidly following illness, if the additional diversified nutrient requirements associated with illness are not met and nutrients are diverted to immune response against infection [8,9]. Despite the global progress in reducing child mortality over the past few decades, an estimated 5.4 million under 5 children died in 2017 and roughly half of these deaths occurred in sub-Saharan Africa [10]. More than 50% of child deaths are attributed to common childhood illness, of these 60% were attributed to malnutrition that associated with an inappropriate child feeding practice [11][12][13]. In Ethiopia, 38% of children are stunted, 10% are wasted, and 24% are underweight which informed the occurrence of both acute and chronic under nutrition. Only 7% and 47.7% of children received the minimum dietary diversity and meal frequency, respectively [14].
The cause of inappropriate feeding practices is multi-factorial and has diverse contributing factors [15]. Socio-economic and demographic characteristics, household family size, cultural and traditional beliefs were identified in previous studies [16,17]. However, those studies were not specifically focused on meal frequency and dietary diversity practices among children who had common childhood illnesses. Feeding (IYCF) and the 2008 National Nutrition Program to improve the levels of child feeding practices [19,20], malnourished children, particularly those with severe acute malnutrition, have a higher risk of death from common childhood illness such as diarrhea, pneumonia, and malaria and Ethiopia still in the list of nations with low levels of meal frequency and poor dietary diversity practices. Therefore, we aimed to assess the magnitude and factors associated with minimum meal frequency and dietary diversity practices among children aged 6-59 months who had an illness.

Study setting and design
This study was based on the baseline survey of five-year project entitled 'Establishing Nutrition The baseline survey included all children under five years, adolescents, pregnant and lactating mothers living in the Dabat HDSS site. Particularly, data on nutrition, health status and service utilization of children were gathered. For this study, we considered all children aged 6-59 months with illness. Child illness was ascertained asking the mothers whether her child had any illness within two weeks prior to data collection.
Sample size and sampling procedure A minimum sample size for the study was estimated using single population proportion formula using Epi-info version 7 by considering the following assumptions: 38% as the proportion of adequate dietary diversity among children aged 6-59 months[21], 95% level of confidence, 4% margin of error and 10% non-response rate. Finally, we got 617. Nevertheless, to increase the power of the study we have included all children (1,174) aged 6-59 months with reported illness in the previous two weeks.

Data collection tool and procedure
The baseline survey questionnaire was initially prepared in English and translated into Amharic and retranslated to English with language and public health experts to check the consistency. The questionnaire was pretested in one kebele out of the kebeles under the HDSS site. Experienced 38 data collectors and seven field supervisors who have been permanently working HDSS site were involved in the data collection process. Three days training on interviewing technique and data collection process was given to data collectors and supervisors. Supervisors checked the overall baseline survey on a daily basis.

Assessment of dietary diversity and meal frequency
Assessment of the dietary diversity score (DDS) of each child was started by asking the mother to list all food consumed by the child in the last 24 hours preceding the survey. Then, the reported food items were classified into seven food groups: grains, roots and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry and liver/organ meats); eggs; vitamin-A-rich fruits and vegetables; other fruits and vegetables. Children who got four or more food groups were classified as meeting the minimum dietary diversity; otherwise, they were considered as getting inadequate minimum dietary diversity [2]. A meal frequency of the child was assessed by asking the mother how many times the child took solid, semi-solid or soft foods in the last 24 hours preceding the survey. Accordingly, two or more times for breastfed infants 6 to 8.9 months of age, three or more times for breastfed children 9 to 23.9 months and four times for non-breastfed children 6 to 59 months were considered as children who received a minimum meal frequency [2].

Data processing and analysis
Data were entered into EPI INFO version 7 and analyzed using a Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics, including frequencies and proportions were used to summarize the study variables. A binary logistic regression model was fitted to identify factors associated with a minimum meal frequency and a minimum dietary diversity practices. Variables with P-Values of < 0.2 in the bi-variable analysis were entered in to the multivariable analysis to control for the possible effect of confounders. The Adjusted Odds Ratio (AOR) with a 95% of confidence intervals was used to examine the strength of association, and a P-Values ≤ 0.05 was used to declare the statistical significance in the multivariable analysis.

Results
A total of 1,174 children aged 6-59 months who had at least the common childhood illness in the last two weeks were included for analysis. The mean age (± SD) of the mothers were 29.06 (± 6.58 years) and 1,017(86.6%) were married (Table 1).   On the other hand, increased odds of having adequate meal frequency was illustrated among ill children whose mothers prepared food for their child alone (AOR = 1.9; 95% CI: 1.28, 2.69) compared to counterparts. However, the odds of adequate meal frequency was lower among children aged 6-23 months compared to those aged 24-59 months (AOR = 0.1, 95% CI: 0.06, 0.15)( Table 4). and Southeast Ethiopia (28.5%) [23].The result was higher than national figure of dietary diversity (7%) [14], Northwest Ethiopia (17%) [24], Kenya (17.9%) [25] and Southern Ethiopia (16%) [26]. The discrepancy might be the national report included remote rural areas but in this study most of them (88.7%) were from urban residence and have a chance to purchase food items and the report include children that had illness as well as healthy child but in this study all the study subjects have at least one common childhood illness during the study period and their mothers might have health information about increased food frequency and Varity during illness from health professionals. In addition, most of study subjects in northwest Ethiopia (87%) were from rural residence and might not have access to buy Varity of food groups to improve dietary diversity [24].
The discrepancy might be due to a variation of dietary habit and culture. Furthermore 80% of study participants in southeast Ethiopia were healthier at time of data collection [22], whereas the current study participants have at least one common childhood illness during data collection period, thus the care givers might be encouraged for increasing meal frequency during illness and only 60% of the current study participants were breastfed child while 97% of study participant of northwest Ethiopia [23] and 91.6% of study participants in southeast Ethiopia [22] were currently breastfed during the survey therefore the mothers might not increase meal frequency. The other difference might be most of the surveys in Asian countries used DHS data, which contain large populations with ethnic, cultural, and traditional variations on infant and young child feeding practices.
Mothers had ANC (Antenatal care) visit during pregnancy were more likely provided the recommended dietary diversity for their child compared with the counterpart This finding was supported by a study conducted in India [28]. This could be due to antenatal care service improves maternal counseling and community conversations program about the child feeding practices which enhance the understanding of mothers about how to prepare and feed their children with diversified foods. In addition, 31.8% of mothers who had ANC service provided the minimum recommended dietary diversity while only 17.9% of mothers who didn't had ANC service provided the minimum recommended dietary diversity thus ANC visits may become the key area to inform the care givers about the importance of providing diversified food groups to their children. Accordingly, intensified efforts are needed to improve the level of ANC service utilization for providing nutrition counseling to mothers on IYCF practices.
Mothers who purchased food source for households were more likely provide diversified food for their child compared with mothers obtained food source from home gardens. The finding was strengthened by a report, on which low income countries, like Ethiopia, the consumption of fruits and vegetables that are produced in home garden do not reach even one-third of the minimum recommended daily intake [29]. Furthermore most of the house hold produce monotonous food source that likely to be nutritionally inadequate in protein, fats and micronutrients to fill the recommended daily dietary intake [30].
The higher proportion of children who were delivered in the health institution were more likely provided diversified food than children were delivered at home. explaining the purpose of the study, potential risks and benefits of the study, and the right to withdraw from the study at any time. The participants were also assured that the data was confidential.

Consent to publish
Not applicable

Availability of data and materials
Full data set and materials pertaining to this study can be obtained from corresponding author on reasonable request.

Competing interests
We the authors declare that there is no any competing interest.

Funding
No funding was obtained for this study.

Authors' Contributions
Authors' contributions: GA designed and supervised the study and ensured quality of the data and made a important contribution to the local implementation of the study. EA has cleaned and analyzed the data; as well as interpreted the results and drafted the manuscript.  Figure 1 Types of food groups given to children aged 6-59 months old, Dabat HDSS site, northwest Ethiopia.