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. 2018 May 18;5(5):CD011768.
doi: 10.1002/14651858.CD011768.pub2.

Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under

Affiliations

Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under

Dachi Arikpo et al. Cochrane Database Syst Rev. .

Abstract

Background: Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants.

Objectives: To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants.

Search methods: In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status.

Selection criteria: Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included.

Data collection and analysis: Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically-developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta-analysis using a random-effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach.

Main results: We included 23 studies (from 35 reports) with a total of 11,170 caregiver-infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community-based studies while four were facility-based studies. In addition, 13 of the included studies were cluster-randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding.Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate-quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate-quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low-quality evidence). There was limited (low to very low-quality) evidence of an effect for all growth outcomes.Quality of evidenceThere is moderate to very low-quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes.

Authors' conclusions: Overall, we found evidence that education improves complementary feeding practices.

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Conflict of interest statement

Dachi Arikpo ‐ none known Ededet Sewanu Edet ‐ none known Moriam T Chibuzor ‐ none known Friday Odey ‐ none known Deborah M Caldwell received a Population Health Scientist Fellowship from the Medical Research Council (MRC), UK. The views expressed herein are those of the author and not necessarily those of the MRC.

Figures

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Theoretical model: educational interventions for improving complementary feeding practices FootnotesaGSM: global system for mobile communication.
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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Study flow diagram
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Sensitivity analysis 3. Comparison of different ICC (primary outcomes), outcome: 3.1 duration of exclusive breastfeeding (≥ 4 months of age)
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Sensitivity analysis 3. Comparison of different ICC (primary outcomes), outcome: 3.2 hygiene: handwashing before feeding

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  • doi: 10.1002/14651858.CD011768

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    1. Nikièma L, Huybregts L, Martin‐Prevel Y, Donnen P, Lanou H, Grosemans J, et al. Effectiveness of facility‐based personalized maternal nutrition counseling in improving child growth and morbidity up to 18 months: a cluster‐randomized controlled trial in rural Burkina Faso. PLoS One 2017;12(5):e0177839. [DOI: 10.1371/journal.pone.0177839; PMC5444625; PUBMED: 28542391] - DOI - PMC - PubMed
Olney 2015 {published data only}
    1. Olney DK, Pedehombga A, Ruel MT, Dillon A. A 2‐year integrated agriculture and nutrition and health behavior change communication program targeted to women in Burkina Faso reduces anemia, wasting, and diarrhea in children 3‐12.9 months of age at baseline: a cluster‐randomized controlled trial. The Journal of Nutrition 2015;145(6):1317‐24. [DOI: 10.3945/jn.114.203539; NCT01825226; PUBMED: 25904734] - DOI - PubMed
Owais 2017 {published data only}
    1. Owais A, Schwartz B, Kleinbaum DG, Suchdev PS, Faruque ASG, Das SK, et al. A nutrition education program in rural Bangladesh was associated with improved feeding practices but not with child growth. The Journal of Nutrition 2017;147(5):948‐54. [DOI: 10.3945/jn.116.243956; PUBMED: 28298543] - DOI - PubMed
Pachon 2002 {published data only}
    1. Marsh DR, Pachón H, Schroeder DG, Ha TT, Dearden K, Lang TT, et al. Design of a prospective, randomised evaluation of an integrated nutrition program in rural Viet Nam. Food and Nutrition Bulletin 2002;23(4 Suppl):36‐47. [PUBMED: 12503230] - PubMed
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Pant 1996 {published data only}
    1. Pant CR, Pokharel GP, Curtale F, Pokhrel RP, Grosse RN, Lepkowski J, et al. Impact of nutrition education and mega‐dose vitamin A supplementation on the health of children in Nepal. Bulletin of the World Health Organization 1996;74(5):533‐45. [PMC2486860; PUBMED: 9002334] - PMC - PubMed
Pelto 2004 {published data only}
    1. Pelto GH, Santos I, Gonçalves H, Victora C, Martines J, Habicht JP. Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition. The Journal of Nutrition 2004;134(2):357‐62. [PUBMED: 14747672] - PubMed
Reich 2010 {published data only}
    1. Reich SM, Bickman L, Saville BR, Alvarez J. The effectiveness of baby books for providing paediatric anticipatory guidance to new mothers. Pediatrics 2010;125(5):997‐1002. [DOI: 10.1542/peds.2009-2728; NIHMS191726; PMC2875122] - DOI - PMC - PubMed
Reinsma 2016 {published data only}
    1. Reinsma K, Nkuoh G, Nshom E. The potential effectiveness of the nutrition improvement program on infant and young child feeding and nutritional status in the Northwest and Southwest regions of Cameroon, Central Africa. BMC Health Services Research 2016;16(1):654. [DOI: 10.1186/s12913-016-1899-z; PMC5109805; PUBMED: 27846828] - DOI - PMC - PubMed
Robling 2016 {published data only}
    1. Robling M, Bekkers MJ, Bell K, Butler CC, Cannings‐John R, Channon S, et al. Effectiveness of a nurse‐led intensive home‐visitation programme for first‐time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 2016;387(10014):146‐55. [DOI: 10.1016/S0140-6736(15)00392-X; ISRCTN23019866; PMC4707160; PUBMED: 26474809] - DOI - PMC - PubMed
Roset‐Salla 2016 {published data only}
    1. Roset‐Salla M, Ramon‐Cabot J, Salabarnada‐Torras J, Pera G, Dalmau A. Educational intervention to improve adherence to the Mediterranean diet among parents and their children aged 1‐2 years. EniM clinical trial. Public Health Nutrition 2016;19(6):1131‐44. [DOI: 10.1017/S1368980015002219; PUBMED: 26258462] - DOI - PMC - PubMed
Roy 2005 {published data only}
    1. Roy SK, Fuchs GJ, Mahmud Z, Ara G, Islam S, Shafique S, et al. Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately‐malnourished children in Bangladesh. Journal of Health, Population, and Nutrition 2005;23(4):320‐30. [PUBMED: 16599102] - PubMed
Roy 2007 {published data only}
    1. Roy SK, Jolly SP, Shafique S, Fuchs GJ, Mahmud Z, Chakraborty B, at al. Prevention of malnutrition among young children in rural Bangladesh by a food‐health‐care educational intervention: a randomised, controlled trial. Food and Nutrition Bulletin 2007;28(4):375‐83. [DOI: 10.1177/156482650702800401; PUBMED: 18274163 ] - DOI - PubMed
Salehi 2004 {published data only}
    1. Salehi M, Kimiagar SM, Shahbazi M, Mehrabi Y, Kolahi AA. Assessing the impact of nutrition education on growth indices of Iranian nomadic children: an application of a modified beliefs, attitudes, subjective‐norms and enabling‐factors model. The British Journal of Nutrition 2004;91(5):779‐87. [DOI: 10.1079/BJN20041099; PUBMED: 15137930] - DOI - PubMed
Santos 2001 {published data only}
    1. Santos I, Victora CG, Martines J, Gonçalves H, Gigante DP, Valle NJ, et al. Nutrition counseling increases weight gain among Brazilian children. The Journal of Nutrition 2001;131(11):2866‐73. [PUBMED: 11694610] - PubMed
Savage 2016 {published data only}
    1. Hohman EE, Paul IM, Birch LL, Savage JS. INSIGHT responsive parenting intervention is associated with healthier patterns of dietary exposures in infants. Obesity 2017;25(1):185‐91. [DOI: 10.1002/oby.21705; PMC5189916; PUBMED: 28008749] - DOI - PMC - PubMed
    1. Hohman EE, Savage JS, Paul IM, Birch LL. INSIGHT study parenting intervention to prevent childhood obesity improves patterns of dietary exposures in infants. The FASEB Journal 2016;30(1 Suppl):295.2. [DOI: 10.1096/fasebj.30.1_supplement.295.2] - DOI
    1. Savage JS, Birch LL, Marini M, Anzman‐Frasca S, Paul IM. Effect of the INSIGHT responsive parenting intervention on rapid infant weight gain and overweight status at age 1 year: a randomized clinical trial. JAMA Pediatrics 2016;170(8):742‐9. [DOI: 10.1001/jamapediatrics.2016.0445; NCT01167270; PMC4969142; PUBMED: 27271455] - DOI - PMC - PubMed
Spigelblatt 1991 {published data only}
    1. Spigelblatt L, Lainé‐Ammara G, Arsenault L, Zvagulis I, Pless IB. Influence of follow‐up education of mothers about too early introduction of solid foods to infants [Influence d'une education suivie aupres des meres sur l'introduction trop rapede des solides dans l'alimentation du nourrisson]. Pediatrie 1991;46(5):475‐9. [PUBMED: 1663244] - PubMed
Taylor 2017 {published data only}
    1. Taylor RW, Williams SM, Fangupo LJ, Wheeler BJ, Taylor BJ, Daniels L, et al. Effect of a baby‐led approach to complementary feeding on infant growth and overweight: a randomized clinical trial. JAMA Pediatrics 2017;171(9):838‐46. [DOI: 10.1001/jamapediatrics.2017.1284; ACTRN12612001133820; PMC5710413 [Available on 05‐09‐2018] ; PUBMED: 28692728] - DOI - PMC - PubMed
Thompson 2012 {published data only}
    1. Thompson DA, Joshi A, Hernandez RG, Bair‐Merritt MH, Arora M, Luna R, et al. Nutrition education via a touchscreen: a randomised controlled trial in Latino immigrant parents of infants and toddlers. Academic Pediatrics 2012;12(5):412‐9. [DOI: 10.1016/j.acap.2012.03.020; NCT01272492; PUBMED: 22682718] - DOI - PubMed
Vitolo 2014 {published data only}
    1. Vitolo MR, Louzada ML, Rauber F. Positive impact of child feeding training program for primary care health professionals: a cluster randomized field trial. Revista Brasileira de Epidemiologia 2014;17(4):873‐86. [DOI: 10.1590/1809-4503201400040007; PUBMED: 25388488] - DOI - PubMed
    1. Vitolo MR, Louzada ML, Rauber F, Grechi P, Gama CM. The impact of health workers' training on breastfeeding and complementary feeding practices [Impacto da atualização de profissionais de saúde sobre as práticas de amamentação e alimentação complementar]. Cadernos de Saude Publica 2014;30(8):1695‐707. [DOI: 10.1590/0102-311X00186913; PUBMED: 25210909] - DOI - PubMed
Wambach 2011 {published data only}
    1. Wambach KA, Aaronson L, Breedlove G, Domian EW, Rojjanasrirat W, Yeh HW. A randomized controlled trial of breastfeeding support and education for adolescent mothers. Western Journal of Nursing Research 2011;33(4):486‐505. [DOI: 10.1177/0193945910380408; PUBMED: 20876551 ] - DOI - PubMed
Waswa 2015 {published data only}
    1. Waswa LM, Jordan I, Herrmann J, Krawinkel MB, Keding GB. Community‐based educational intervention improved the diversity of complementary diets in western Kenya: results from a randomized controlled trial. Public Health Nutrition 2015;18(18):3406‐19. [DOI: 10.1017/S1368980015000920; PUBMED: 25857703] - DOI - PMC - PubMed
Yousafzai 2016 {published data only}
    1. Yousafzai AK, Obradović J, Rasheed MA, Rizvi A, Portilla XA, Tirado‐Strayer N, et al. Effects of responsive stimulation and nutrition interventions on children's development and growth at age 4 years in a disadvantaged population in Pakistan: a longitudinal follow‐up of a cluster‐randomised factorial effectiveness trial. Lancet, Global Health 2016;4(8):e548‐58. [DOI: 10.1016/S2214-109X(16)30100-0; NCT00715936; PUBMED: 27342433] - DOI - PubMed
Zaman 2008 {published data only}
    1. Zaman S, Ashraf RN, Martines J. Training in complementary feeding counselling of healthcare workers and its influence on maternal behaviours and child growth: a cluster‐randomised controlled trial in Lahore, Pakistan. Journal of Health, Population, and Nutrition 2008;26(2):210‐22. [PMC2740673; PUBMED: 18686554] - PMC - PubMed
Zhang 2016 {published data only}
    1. Zhang Y, Wu Q, Wang W, Velthoven MH, Chang S, Han H, et al. Effectiveness of complementary food supplements and dietary counselling on anaemia and stunting in children aged 6‐23 months in poor areas of Qinghai Province, China: a controlled interventional study. BMJ Open 2016;6(10):e011234. [DOI: 10.1136/bmjopen-2016-011234; ChiCTRPRC12002444; PMC5093399; PUBMED: 27799239] - DOI - PMC - PubMed

References to studies awaiting assessment

Dunlevy 2010 {published data only}
    1. Dunlevy F, Sheridan‐Pereira M, Koornneef E. Can antenatal education alter the preferred time of weaning?. Journal of Pediatric Gastroenterology and Nutrition 2010;50(Suppl 2):e40‐41. [PD‐N‐099; journals.lww.com/jpgn/toc/2010/06002]
Dunlvey 2012 {published data only}
    1. Dunlevy FB, Sheridan‐Pereira M. Improved timing of fish introduction in infancy. Clinical Nutrition Supplements 2012;7(1):128. [DOI: 10.1016/S1744-1161(12)70312-5; PP261‐SUN] - DOI
Guan 2016 {published data only}
    1. Guan H. Community‐based educational intervention improved caregivers feeding behaviors and the nutritional anemia in infant aged 6‐11 months: a randomized controlled trial in rural China. European Journal of Pediatrics 2016;175(11):1487‐88. [DOI: 10.1007/s00431-016-2785-8; 283] - DOI
Jordan 2015 {published data only}
    1. Jordan I, Kuchenbecker J, Phiri GC, Mühlhoff E, Herrmann J, Krawinkel MB. Food based nutrition education improved complementary feeding practices and nutritional status of children below 2 years in Malawi. Annals of Nutrition and Metabolism 2015;67(Suppl 1):471‐2. [DOI: 10.1159/000440895; 149/1396] - DOI
Palacios 2017 {published data only}
    1. Palacios C, Campos M, Gibby C, Banna J. Multi‐site trial using short mobile messages (SMS) to improve infant feeding practices among participants in the WIC program. The FASEB Journal 2017;31(1 Suppl):959.8. [DOI: 10.1096/fasebj.31.1_supplement.959.8] - DOI
Paul 2011 {published data only}
    1. Paul IM, Savage JS, Anzman SL, Beiler JS, Marini ME, Stokes JL, et al. Preventing obesity during infancy: a pilot study. Obesity 2011;19(2):353‐61. [DOI: 10.1038/oby.2010.182; NCT00359242; PMC3477360; PUBMED: 20725058] - DOI - PMC - PubMed
Rabadi 2013 {published data only}
    1. Rabadi H, Al Sharif N. Community based intervention improves infant feeding practices in Bethlehem villages. Annals of Nutrition and Metabolism 2013;63(Suppl 1):401. [DOI: 10.1159/000354245; P0302] - DOI
Savage 2010 {published data only}
    1. Savage JS, Paul IM, Marini ME, Birch LL. Pilot intervention promoting responsive feeding, the division of feeding responsibility, and healthy dietary choices during infancy. Appetite 2010;54(3):673. [DOI: 10.1016/j.appet.2010.04.178] - DOI
Shafique 2013 {published data only}
    1. Shafique S, Chowdhury J, Jolly S, Shikder H, Sellen D, Zlotkin S. Prevention of linear growth faltering among low birth weight infants in rural Bangladesh: a community‐based cluster randomised trial. Annals of Nutrition and Metabolism 2013;63(Suppl 1):1127‐8. [DOI: 10.1159/000354245; P03332] - DOI
    1. Shafique S, Jalal CSB, Jolly SP, Shikder H, Sellen DW, Zlotkin S. Effects of water‐based hand sanitizers and micronutrient powders along with nutrition and hygiene education to prevent infections and linear growth faltering among low birth weight infants in Bangladesh. The FASEB Journal 2013;27(1 Suppl):243.1. [DOI: 10.1096/fasebj.27.1_supplement.243.1] - DOI
    1. Shafique S, Singla D, Aboud F, Jolly S, Zlotkin S. Multiple micronutrient powders reduce stunting and anaemia and improve language development among full‐term low birth weight children in Bangladesh. The FASEB Journal 2014;28(1 Suppl):389.3. [DOI: 10.1096/fasebj.28.1_supplement.389.3] - DOI
Toure 2016 {published data only}
    1. Toure D, Rawat R, Stoltzfus RJ, Harvey D, Mwanamwenge M, Pelletier DL. The effects of a nutrition‐sensitive agricultural intervention on social support, food security and maternal self‐efficacy in complementary feeding. The FASEB Journal 2016;30(1 Suppl):247.4. [DOI: 10.1096/fasebj.30.1_supplement.274.4] - DOI

References to ongoing studies

Campbell 2016 {published data only}
    1. Campbell KJ, Hesketh KD, McNaughton SA, Ball K, McCallum Z, Lynch J, et al. The Extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) Program: a cluster‐randomized controlled trial of an early intervention to prevent childhood obesity. BMC Public Health 2016;16:166. [DOI: 10.1186/s12889-016-2836-0; ACTRN12611000386932; PMC4758178; PUBMED: 26888759] - DOI - PMC - PubMed
Cloutier 2015 {published data only}
    1. Cloutier MM, Wiley J, Wang Z, Grant A, Gorin AA. The Early Childhood Obesity Prevention Program (ECHO): an ecologically‐based intervention delivered by home visitors for newborns and their mothers. BMC Public Health 2015;15:584. [DOI: 10.1186/s12889-015-1897-9; NCT02052518; PUBMED: 26104068] - DOI - PMC - PubMed
Helle 2017 {published data only}
    1. Helle C, Hillesund ER, Omholt ML, Øverby NC. Early food for future health: a randomized controlled trial evaluating the effect of an eHealth intervention aiming to promote healthy food habits from early childhood. BMC Public Health 2017;17(1):729. [DOI: 10.1186/s12889-017-4731-8; PMC5607575; PUBMED: 28931384] - DOI - PMC - PubMed
Hernes 2013 {published data only}
    1. Hernes S, Haugen M, Øverby N. First food for infants. Annals of Nutrition and Metabolism 2013;63(Suppl 1):326‐7. [DOI: 10.1159/000354245; P0148] - DOI
Horodynski 2011 {published data only}
    1. Horodynski MA, Olson B, Baker S, Brophy‐Herb H, Auld G, Egeren L, et al. Healthy babies through infant‐centred feeding protocol: an intervention targeting early childhood obesity in vulnerable populations. BMC Public Health 2011;11:868. [DOI: 10.1186/1471-2458-11-868; ACTRN126100000415000; PMC3339510; PUBMED: 22085421] - DOI - PMC - PubMed
Horodynski 2015 {published data only}
    1. Horodynski MA, Silk K, Hsieh G, Hoffman A, Robson M. Tools for teen moms to reduce infant obesity: a randomised clinical trial. BMC Public Health 2015;15:22. [DOI: 10.1186/s12889-015-1345-x; NCT02244424; PMC4308927; PUBMED: 5604090] - DOI - PMC - PubMed
Kimani‐Murage 2013 {published data only}
    1. Kimani‐Murage EW, Kyobutungi C, Ezeh AC, Wekesah F, Wanjohi M, Muriuki P, et al. Effectiveness of personalised, home‐based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: study protocol for a cluster randomised controlled trial. Trials 2013;14:445. [DOI: 10.1186/1745-6215-14-445; ISRCTN83692672; PUBMED: 24370263] - DOI - PMC - PubMed
Kulwa 2014 {published data only}
    1. Kulwa KB, Verstraeten R, Bouckaert KP, Mamiro PS, Kolsteren PW, Lachat C. Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania: rationale, design and methods of a cluster randomised trial. BMC Public Health 2014;14:1077. [DOI: 10.1186/1471-2458-14-1077; NCT02249754; PMC4216379; PUBMED: 25318980] - DOI - PMC - PubMed
SHINE Team 2015 {published data only}
    1. Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team, Humphrey JH, Jones AD, Manges A, Mangwadu G, Maluccio JA, et al. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial: rationale, design, and methods. Clinical Infectious Diseases 2015;61(Suppl 7):S685‐702. [DOI: 10.1093/cid/civ844; NCT01824940; PMC4657589; PUBMED: 26602296] - DOI - PMC - PubMed
Wasser 2015 {published data only}
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