Literature search findings
The database search provided a total of 207 articles, of which 19 were eligible for full-text review. The remaining studies which were not SRM studies were excluded because the objective of this study was to include only SRM studies on the topics of interest. After full text reviewing, 8 studies were found eligible for inclusion. Additionally, one article was found by hand searching of the reference lists of the included studies. Thus, a total of 9 studies [4, 16-23] were included in the current umbrella review. The study selection and screening process is shown in Fig. 1. We aimed to include anemia in this umbrella review, but no SRM report was found on it.
Characteristics of included studies
All SRM studies included in this review were observational in design. They included a total of 255 studies, providing a total sample of 214,458 under-5 children. The number of studies per SRM ranged from 14 (lowest) [23] to 70 (highest) [21]. The sample size per meta-analysis ranged 13,531 (lowest)[23] to 55,000 (highest) [21]. All studies were published from 2017 to 2019. The specific malnutrition conditions assessed by the SRM studies were stunting, wasting, and underweight. Two meta-analyses were done on the prevalence and the determinants of stunting, underweight, and wasting [4, 16]. The specific IYCF practice indicators assessed were exclusive breastfeeding, early initiation of breastfeeding, timely initiation of complementary feeding, dietary diversity, meal frequency, and minimum acceptable diet. Seven studies were done on both the magnitude and the determinants of IYCF practices [17-23]. The overall characteristics of the included studies, including the topic they addressed, is shown in Table 1.
Table 1: General characteristics of included systematic review and meta-analyses studies.
Author (year)
|
Study
design
|
Age
(months)
|
Included
studies
|
Sample
size
|
Main
topic
|
Main
measure
|
AMSTAR
Quality
|
Abdulahi [4]
(2017)
|
Survey
|
<60
|
18
|
39,585
|
- Stunting
- Underweight
- Wasting
|
Prevalence
|
10
|
Abdurahman
(2019) [17]
|
Survey
|
6-23
|
26
|
17, 383
|
- Timely initiation of breastfeeding
- Minimum dietary diversity
- Minimum meal frequency
- Minimum acceptable diet
|
|
9
|
Alebel
(2017) [18]
|
Survey
|
6-23
|
16
|
18,870
|
Timely initiation of breastfeeding
|
|
5
|
Habtewold
(2018) [21]
|
Survey
|
6-23
|
70
|
55,000
|
- Timely initiation of breastfeeding
- Exclusive breastfeeding
- Timely initiation of breastfeeding
|
|
10
|
Temesgen
(2019) [23]
|
Survey
|
6-23
|
14
|
13,531
|
Minimum dietary diversity
|
|
8
|
Abate
(2019) [16]
|
Survey
|
<60
|
23
|
18,172
|
Stunting
|
Determinants
|
5
|
Alebel
(2018) [19]
|
Survey
|
6-23
|
32
|
23,543
|
Exclusive breastfeeding
|
Prevalence
|
5
|
Habtewold
(2019) [22]
|
Survey
|
6-23
|
25
|
31,066
|
Timely initiation of breastfeeding
|
Determinants
|
10
|
Habtewold
(2019) [20]
|
Survey
|
6-23
|
31
|
14,691
|
Exclusive breastfeeding
|
Determinants
|
10
|
AMSTAR, Assessment of Multiple Systematic Reviews.
Methodological quality of included studies
Table 2 shows the methodological quality of the included studies, evaluated using the AMSTAR tool for assessment of the methodological quality of SRM studies [27]. The quality scoring was done out of 11 points and ranged from 5 to 10, with a mean score of 7.8 points, indicating an overall moderate quality. The AMSTAR criteria more frequently satisfied across the studies were the ones about the assessment of publication bias and disclosure of conflict of interest. The AMSTAR criteria less frequently satisfied were the ones about inclusion and exclusion of studies and priori design.
Table 2: Methodological quality of the included studies based on the AMSTAR tool.
Author, year
|
Q1
|
Q2
|
Q3
|
Q4
|
Q5
|
Q6
|
Q7
|
Q8
|
Q9
|
Q10
|
Q11
|
Total
|
Habtewold (2018) [21]
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
10
|
Abdurahman (2019) [17]
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
9
|
Temesgen (2019) [23]
|
No
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
8
|
Alebel (2017) [18]
|
No
|
Yes
|
No
|
No
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
5
|
Abdulahi(2017) [4]
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
10
|
Alebel (2018) [19]
|
No
|
Yes
|
No
|
No
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
5
|
Habtewold (2019) [22]
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
10
|
Habtewold (2019) [20]
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
10
|
Abate (2019) [16]
|
No
|
Yes
|
No
|
Yes
|
No
|
No
|
Yes
|
No
|
No
|
Yes
|
Yes
|
5
|
AMSTAR, Assessment of Multiple Systematic Reviews.
Q1: A priori design; Q2: Duplicate study selection and data extraction; Q3: Search comprehensiveness; Q4: Inclusion of grey literature; Q5: Included and excluded studies provided; Q6: Characteristics of the included studies provided; Q7: Scientific quality of the primary studies assessed and documented; Q8: Scientific quality of included studies used appropriately in formulating conclusions; Q9: Appropriateness of methods used to combine studies’ findings; Q10: Likelihood of publication bias was assessed; Q11: Conflict of interest – potential sources of support were clearly acknowledged in both the systematic review and the included studies.
Magnitude and determinants of malnutrition
The SRM studies on the magnitude and determinants of malnutrition included a total of 41 cross-sectional studies, covering a total sample of 57,757 under-5 children. The summary pooled prevalence of stunting, as defined by WHO height-for-age Z-scores below 2 standard deviations (SD) from the median of the reference population, was 42% (95%CI=37-46%). The summary pooled prevalence of underweight, as defined by WHO weight-for-age Z-scores below 2SD from the median of the reference population, was 33% (95%CI= 27-39%). The summary pooled prevalence of wasting, as defined by WHO weight-for-height Z-scores below 2SD from the median of the reference population, was 15% (95%CI=12-19%). The summary estimates of the prevalence of malnutrition are shown in Table 3.
Table 3: Summary of the prevalence of malnutrition and indicators of child feeding practices.
Variable or indicator
|
Reference
|
No. of
Studies
|
Sample
size
|
Reported prevalence
|
Summary prevalence*
|
P(95%CI)
|
I2(%)
|
P(95%CI)
|
I2(%)
|
Stunting
|
Abdulahi (2017) [4]
|
18
|
39,585
|
42(37-46)
|
98.5
|
42(37-46)
|
98.5
|
Underweight
|
Abdulahi (2017) [4]
|
17
|
28,169
|
33(27-39)
|
99.0
|
33(27-39)
|
99.0
|
Wasting
|
Abdulahi (2017) [4]
|
16
|
30,658
|
15(12-19)
|
98.9
|
15(12-19)
|
98.9
|
Timely breastfeeding initiation
|
Habtewold (2018) [21]
|
45
|
47,858
|
67(62-71)
|
99.0
|
65(65-66)
|
1.9
|
Alebel (2017) [18]
|
16
|
18,870
|
61(51-72)
|
99.4
|
Exclusive breastfeeding
|
Habtewold (2018) [21]
|
40
|
25,816
|
60(56-65)
|
98.0
|
60(59-60)
|
0.0
|
Alebel (2018) [19]
|
32
|
23,543
|
59(54-65)
|
98.7
|
Timely complementary feeding initiation
|
Habtewold (2018) [21]
|
21
|
55,000
|
63(57-68)
|
97.0
|
62(61-63)
|
4.1
|
Abdurahman (2019) [17]
|
14
|
17,383
|
61(52-70)
|
98.5
|
Minimum dietary diversity
|
Abdurahman (2019) [17]
|
19
|
17, 383
|
18(11-25)
|
99.5
|
20(19-21)
|
2.8
|
Temesgen (2019) [23]
|
14
|
13,531
|
23(18-29)
|
98.8
|
Minimum meal frequency
|
Abdurahman (2019) [17]
|
14
|
17, 383
|
56(45-66)
|
99.2
|
56(45-66)
|
99.2
|
Minimum acceptable diet
|
Abdurahman (2019) [17]
|
8
|
17, 383
|
10(07-14)
|
91.5
|
10(07-14)
|
91.5
|
*Calculated with random-effects meta-analysis model.
P, Prevalence; CI, Confidence interval.
The multi-dimensional factors, i.e. dietary and non-dietary factors, found linked to any of the three malnutrition conditions are shown in Table 4. Of these, the most frequently mentioned dietary factors founded linked to high risk of malnutrition (stunting, underweight, and wasting) were late initiation of breastfeeding, non-exclusive breastfeeding during the first six months, late initiation of complementary feeding, and low diversity and frequency of complementary feeding. Environmental factors found often associated with a high risk of malnutrition were an unimproved household water source, unimproved household toilet facility, and rural place of residence. Health factors found often associated with a high risk of malnutrition were childhood infection, home delivery, lack of immunization, family planning, antenatal and postnatal care, and poor utilization of micronutrient supplements like iron, vitamin A, and prophylaxis medications like deworming. There was significant variation in the magnitude of malnutrition by children's sex and age; such that, there was a significant difference in the prevalence of stunting, wasting, and underweight by age and sex.
Table 4: Summary of risk factors of malnutrition and poor IYCF practices.
Outcome
|
Risk factors
|
Malnutrition
|
Dietary/Feeding [4, 16]
|
Poor breastfeeding and complementary feeding
|
Food insecurity
|
Health [4, 16]
|
Lack of antenatal care
|
Lack of postnatal care
|
Deworming
|
Vitamin A supplementation
|
Immunization
|
Counseling
|
Infection
|
Place of delivery
|
Sociodemographic [4, 16]
|
Child sex
|
Child age
|
Maternal education status
|
Wealth (income)
|
Family size
|
Media exposure
|
Hygiene [4, 16]
|
Type water source
|
Type of toilet facility
|
Environmental [4, 16]
|
Place of residence
|
IYCF practices
|
Health [17-23]
|
Lack of antenatal care
|
Lack of postnatal care
|
Place of delivery
|
Sociodemographic [17-23]
|
Child sex
|
Child age
|
Maternal education status
|
Wealth (income)
|
Family size
|
Media exposure
|
Paternal involvement
|
IYCF knowledge
|
Breastfeeding experience
|
Environmental [17-23]
|
Place of residence
|
IYCF, Infant and young child feeding.
Magnitude and determinants of IYCF practice indicators
Seven SRM studies were done on the magnitude and determinants of suboptimal IYCF practice indicators. The specific IYCF indicators assessed were early initiation of breastfeeding, exclusive breastfeeding, timely initiation of complementary feeding, minimum dietary diversity, minimum meal frequency, and minimum acceptable diet. No SRM report was found on the duration of breastfeeding. The reported estimate of the level of early initiation of breastfeeding ranged from 61% (95%CI=51-72%) to 67% (95%CI= 62-71%) and the pooled prevalence (calculated summary) estimate was 65% (65-55%); such that, two-thirds of children were fed with breast milk within the first one hour after birth. The reported estimate of the level of exclusive breastfeeding ranged from 59% (95%CI=54-65%) to 60% (95%CI=56-65%) and the pooled prevalence (calculated summary) estimate was 60% (95%CI=59-60%). The reported estimate of the level of timely initiation of complementary feeding ranged from 61% (95%CI=52-70%) to 63% (95%CI=57-68%) and the pooled prevalence (calculated summary) estimate was 62% (95%CI=61-63%). The reported estimate of the proportion of children who met the minimum dietary diversity ranged from 18% (95%CI=11-25%) to 23% (95%CI=18-29%) and the pooled (calculated summary) estimate was 20% (95%CI=19-21%). The summary estimates of the proportion of children who met the minimum meal frequency and the minimum acceptable diet were 56.0% (95%CI=45-66%) and 10.0% (95%CI=7-14%), respectively. Table 3 shows the reported and calculated (pooled) summary estimates of IYCF practices.
Seven SRM studies [17-23] examined factors associated with sub-optimal IYCF practices and reported a number of health, sociodemographic, and environmental factors. Home delivery (i.e., instead of intuitional delivery), not attending antenatal care, postnatal care, and nutritional counseling services were the main health-related factors often found linked to sub-optimal IYCF practices. Low caregivers’ educational status, poor household socioeconomic status (low wealth category), low caregivers’ media exposure, paternal involvement in child’s care, household family size, and maternal breastfeeding experience were the main sociodemographic found linked to poor IYCF practices. Like the case of malnutrition, there was also significant variation in IYCF practices by children's sex and age. Rural residence was the main environmental or household factor found linked to poor IYCF practices.