mother is temporarily ill and unable to breastfeed, the recommendation is to express and heat-treat the breastmilk before providing it to the infant [11]. These recommendations were informed by the results of multiple IYCF interventions and systematic reviews [11, 12].
While the WHO and UNICEF guidelines are global recommendations, some countries have their own national IYCF guidelines as well. For example, in 2015, India finalized their Optimal and Appropriate Infant and Young Child Nutrition Practices and Strategies after consulting with a variety of infant feeding experts such as partners from the WHO, UNICEF, Ministry of Child Welfare Department, and the Human Milk Banking Association of India [13]. Most of these guidelines align with the WHO and UNICEF recommendations, including the guideline that specifies to practice responsive feeding (RF). For caregivers, RF involves recognizing and encouraging a child’s hunger and fullness cues and responding accordingly [14, 15]. The importance and the impact of RF are discussed further below.
Assessment of IYCF
Many early childhood nutrition interventions and programs target IYCF practices. To assess the potential effect of these interventions, the WHO has published 15 IYCF indicators [16]. Eight of the 15 are classified as core, these include early initiation of breastfeeding, exclusive breastfeeding under 6 months, continued breastfeeding for 1 year, introduction of solid, semi-solid, or soft foods, consumption of iron-rich or iron-fortified foods, minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) [16]. These indicators provide the ability to evaluate and track feeding practices and patterns both within a country and globally.
Adherence to IYCF Recommendations
Breastfeeding
Early initiation of breastfeeding, within the first hour of life, provides many benefits to the newborn infant. First, it ensures the infant receives colostrum. Colostrum is important because it is rich in antibodies that confer passive immunity to the infant [7, 17]. Compared to infants who were put to breast within 1 hour of birth, the risk of death is 41% higher for those who initiated 2–23 h after birth and 79% higher for those who initiated 1 day or longer after birth [7]. Globally, only 41% of infants were put to breast within 1 hour of birth between years 2013 and 2018 [18]. East Asia and the Pacific region had the lowest rates with 32%, while the highest rates occurred in Eastern and Southern Africa at 65% [18]. In India, a nationally representative household survey conducted in 2015–2016 found that 41.6% of children under 3 years old had been breastfed within 1 hour of birth. This was a positive increase compared to the survey conducted in 2005–2006, where 23.4% of children under 3 years old had been breastfed within 1 hour of birth (Table 1) [19, 20].
Table 1. Child feeding practices and nutritional status of children in India comparing NFHS-4 and NFHS-3
In addition to the multiple benefits of early initiation, breastfeeding initiation within the first hour of life increases the likelihood of exclusive breastfeeding through the first 6 months [7]. Despite the important benefits of breastfeeding, less than half of all infants are exclusively breastfed through the first 6 months of life [18]. The most recent data from UNICEF show global exclusive breastfeeding rates at 41%. East Asia and the Pacific region had the lowest rates of exclusive breastfeeding at 22%, while Eastern and Southern Africa had the highest rates at 56% [18]. Within India, the exclusive breastfeeding rate was 54.9% in 2015–2016, compared to 46.4% in 2005–2006 (Table 1) [19, 20].
Multiple factors influence why mothers do not exclusively breastfeed, including beliefs and cultural norms [21]. Mothers encounter multiple challenges that discourage exclusive breastfeeding through 6 months of age. Prenatally, women who lack access to breastfeeding information and education are less likely to initiate after birth [22]. During labor, both the maternal labor experience and the breastfeeding attitudes of the hospital staff can impact the maternal breastfeeding intention, which is associated with early weaning [23]. In the postpartum period, women who have clinical problems, such as low supply or problems with infant latch, are more likely to discontinue breastfeeding. Women who identify a lack of clinical/provider support are more likely to discontinue breastfeeding before 6 months. Also, women who return to work before 6 months are less likely to be exclusively breastfeeding for 6 months [24-26].
Complementary Feeding
As noted above, the guidelines recommend exclusive breastfeeding until infants are 6 months of age with the gradual introduction of nutritionally safe and adequate complementary foods [6]. To measure adequacy of CF, the WHO indicators defined above are used: MDD, MMF, and MAD [16]. Dietary diversity reflects a nutritionally adequate diet. Children aged 6–23 months should eat food from at least 4 of the following food groups a day: grains, roots and tubers, legumes and nuts, dairy products, meat and fish, eggs, Vitamin A-rich fruits and vegetables, and other fruits and vegetables. A diet lacking in diversity can increase a child’s risk of micronutrient deficiencies [7]. Yet, only 29% of the world’s children meet the requirements [27]. Additionally, children need to eat frequently throughout the day to meet their energy and nutrient requirements. However, only 50% of young children (6–23 months) are meeting the MMF requirements. Among children under 2 years old, there is an equity gap between rich and poor for both MDD and MMF [7]. Globally, children from poorer households consume less diverse and more infrequent meals compared to those from richer households. Low maternal education levels and maternal media exposure were also associated with suboptimal CF practices in multiple countries [28-
