Feeding, caregiving practices, and developmental delay among children under five in lowland Nepal: a community-based cross-sectional survey

Abstract

Background: Nurturing care, including adequate nutrition, responsive caregiving and early learning, is critical to early childhood development. In Nepal, national surveys highlight inequity in feeding and caregiving practices for young children. Our objective was to describe infant and young child feeding (IYCF) and cognitive and socio-emotional caregiving practices among caregivers of children under five in Dhanusha district, Nepal, and to explore socio-demographic and economic factors associated with these practices.

Methods: We did a cross-sectional analysis of a subset of data from the MIRA Dhanusha cluster randomised controlled trial, including mother-child dyads (N = 1360), sampled when children were median age 46 days and a follow-up survey of the same mother-child dyads (N = 1352) when children were median age 38 months. We used World Health Organization IYCF indicators and questions from the Multiple Indicator Cluster Survey-4 tool to obtain information on IYCF and cognitive and socio-emotional caregiving practices. Using multivariable logistic regression models, potential explanatory household, parental and child-level variables were tested to determine their independent associations with IYCF and caregiving indicators.

Results: The prevalence of feeding indicators varied. IYCF indicators, including ever breastfed (99%), exclusive breastfeeding (24-hour recall) (89%), and vegetable/fruit consumption (69%) were common. Problem areas were early initiation of breastfeeding (16%), colostrum feeding (67%), no pre-lacteal feeding (53%), timely introduction of complementary feeding (56%), minimum dietary diversity (49%) and animal-source food consumption (23%). Amongst caregiving indicators, access to 3+ children's books (7%), early stimulation and responsive caregiving (11%), and participation in early childhood education (27%) were of particular concern, while 64% had access to 2+ toys and 71% received adequate care. According to the Early Child Development Index score, only 38% of children were developmentally on track. Younger children from poor households, whose mothers were young, had not received antenatal visits and delivered at home were at higher risk of poor IYCF and caregiving practices.

Conclusions: Suboptimal caregiving practices, inappropriate early breastfeeding practices, delayed introduction of complementary foods, inadequate dietary diversity and low animal-source food consumption are challenges in lowland Nepal. We call for urgent integrated nutrition and caregiving interventions, especially as interventions for child development are lacking in Nepal.

Keywords: Caregiving; Early child development; Feeding; Infant; Nepal; Young children.

Fig. 1

Conceptual framework for determinants of feeding and caregiving practices. Single-headed solid black and dotted blue arrows represent directional paths, and double-headed arrows indicate the variables that are assumed to be correlated

Fig. 2

Final adjusted model showing factors affecting breastfeeding practices among children aged 0–12 months. The median age of children for three breastfeeding indicators - early time of initiation of breastfeeding, colostrum feeding and no pre-lacteal feeding were 46 days (range 0–12 months) and for exclusive breastfeeding (24-hours recall) was 45 days (range 0–5 months). Each model was adjusted for the effect of clustering using cluster sites as a random effect and study trial arms as a fixed effect. We adjusted all breastfeeding indicators by child’s age in months at recall as a continuous variable in the multivariable regression models

Fig. 3

Final adjusted model showing factors affecting complementary feeding practices among children of median age 38 months (range 7–59 months). Each model was adjusted for the effect of clustering using cluster sites as a random effect and study trial arms as a fixed effect. CF: Complementary Feeding

Fig. 4

Final adjusted model showing factors affecting caregiving practices among children of median age 38 months (range 7–59 months). Each model was adjusted for the effect of clustering using cluster sites as a random effect and study trial arms as a fixed effect. The age denominator for access to 3+ children’s books and 2+ toys is 7–59 months; support for learning is 24–59 months

Fig. 5

Final adjusted model showing factors affecting caregiving practices among children aged 7–59 months. Each model was adjusted for the effect of clustering using cluster sites as a random effect and study trial arms as a fixed effect. ECE: Early Childhood Education; ECDI: Early Childhood Development Index. The age denominator for adequate supervision is 7–59 months; participation in ECE and ECDI score is 36–59 months

Fig. 6

Venn diagram showing shared risk factors between feeding and caregiving indicators. The area where the circles overlap denote factors commonly identified as significant factors for each infant and young child feeding and cognitive and socio-emotional caregiving indicator showing the same direction of association for each outcome in multivariable regression analysis Model 3. EIBF Early Initiation of Breastfeeding, EBF Exclusive Breastfeeding, CF Complementary Feeding, HH Household, MDD Minimum Dietary Diversity, ECE Early Childhood Education, ECDI Early Childhood Development Index