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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 49-53

Feeding problems in a sample of children under 5 years at a primary health-care center in Erbil, Iraq


1 Department of Community, Brayatee Healthcare Center, Erbil, Iraq
2 Department of Community, College of Medicine, Hawler Medical University, Erbil, Iraq

Date of Submission27-Nov-2020
Date of Acceptance01-Dec-2020
Date of Web Publication17-Mar-2021

Correspondence Address:
Faiza Jalil Ahmed
Department of Community, Brayate Health Care Center, Erbil
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJBL.MJBL_86_20

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  Abstract 


Background: The feeding issues of children under 5 years of life have effects on overall growth and development. Objectives: This study aimed to find out the prevalence of feeding problems and their associated factors among a sample of children under 5 years visiting a primary health-care center in Erbil city. Materials and Methods: In this cross-sectional study, the mothers who visited the primary health centers for the medical checkup of their children under 5 years were consecutively screened for the eligibility criteria between February 1, 2020, and June 30, 2020. Results: The children were located in the following age groups: 6–9 months (11.3%), 9–12 months (4.9%), 12–24 months (32.0%), and >24 months (51.7%). The children had an abnormal height for age (8.9%), weight for age (6.9%), and weight for height (14.3%). The prevalence of formula feeding was 49.0% in children. The prevalence of feeding problems was 75.9%, including mono-feeding (20.2%) and multi-feeding issues (55.7%). The prevalence of complementary food was 2.0% only. The prevalence of active feeding was 54.2%. The study showed that younger age group had a significantly higher prevalence of feeding problem (P < 0.001). The study showed that children with abnormal weight for age were more likely to have feeding problems compared to those with a normal weight for age (100% vs. 74.1%, P = 0.019), respectively. Conclusions: The present study showed that a considerable percentage of children have feeding issues. The feeding issues were higher in younger age groups.

Keywords: Breastfeeding, children, nutrition, pediatric population


How to cite this article:
Ahmed FJ, Sulaiman KH. Feeding problems in a sample of children under 5 years at a primary health-care center in Erbil, Iraq. Med J Babylon 2021;18:49-53

How to cite this URL:
Ahmed FJ, Sulaiman KH. Feeding problems in a sample of children under 5 years at a primary health-care center in Erbil, Iraq. Med J Babylon [serial online] 2021 [cited 2021 May 18];18:49-53. Available from: https://www.medjbabylon.org/text.asp?2021/18/1/49/311456




  Introduction Top


Adequate feeding is essential for the infant's health, growth, and development. Poor feeding during infancy increases the risk of infection and death. Poor feeding also impairs growth and may have lifelong effects such as increasing the risk of poor development or obesity.[1],[2]

Breast milk is an important source of energy and nutrients in children aged 6–23 months. It can provide half or more of a child's energy needs between the ages the 6 and 12 months, and one-third of energy needs between 12 and 23 months. Breast milk is also a critical source of energy and nutrients during illness and reduces mortality among children who are malnourished. Children and adolescents who were breastfed as babies are less likely to be overweight or obese.[3]

Around the age of 6 months, an infant's needs for energy and nutrients start to exceed what is provided by milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant's growth may falter.[4],[5]

Guiding principles for appropriate complementary feeding are:

  • Continue frequent, on-demand breastfeeding until 2 years of age or beyond
  • Practice responsive feeding (for example, feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child, and maintain eye contact)
  • Practice good hygiene and proper food handling
  • Start at 6 months with small amounts of food and increase gradually as the child gets older
  • Gradually increase food consistency and variety
  • Increase the number of times that the child is fed: 2–3 meals per day for infants aged 6–8 months. The children of 3–4 months are fed by fortified complementary food or vitamin–mineral supplements as needed
  • Use fortified complementary foods or vitamin–mineral supplements as needed
  • During illness, increase fluid intake including more breastfeeding, and offer soft, favorite foods (source IMCI, module 2+ infant and young child feed/WHO/April 2020).


The 2019 edition of SOWC explored the issue of children, food, and nutrition. Significant progress has been made over the past two decades, but one-third of children under the age of 5 years are considered to be malnourished – stunted, wasted, or overweight. Besides, two-third of children are at risk of malnutrition and hidden hunger because of the poor quality of their diets. The main The State of the World's Children challenge to this issue is a broken food system that unable to provide suitable and required diets.[6]

The World Health Organization (WHO) has reported that 2.7 million child deaths annually or 45% of all child deaths are contributed to undernutrition. Infant and young child feeding are considered to have a crucial role in improving child survival and promoting healthy growth and development. The first 2 years of a child is so critical for optimal nutrition to decrease morbidity and mortality, chronic diseases, and to encourage better development. Optimal breastfeeding saves annually 820,000 children under the age of 5 years.[7] Only 37.0% of the children younger than 6 months of age are exclusively breasted in low-income and middle-income countries. Therefore, it is so important to explore the feeding issues of children under 5 years of life due to its effect on overall growth and development.[8]

The aim of this study was to identify feeding problems among a sample of children under 5 years visiting a primary health-care center in Erbil city. Specific objectives included determination of the prevalence of feeding problems in children under 5 years of age, the association between feeding problems and related factors including sociodemographic characteristics of the child and his/her family, as well as finding out types of feeding problems in children under 5 years of age.


  Materials and Methods Top


Study design and sampling

A cross-sectional study was conducted in Erbil city, the capital of the Kurdistan Region of Iraq. The mothers who visited the primary health centers (PHCs) for the medical checkup of their children under 5 years were consecutively screened for the eligibility criteria. The children who were required for the study were selected consecutively in a nonprobability way. The subjects were selected from the following PHCs: Zhyan, Shahedan, Tayrawa, and Shady in Erbil city between February 1, 2020, and June 30, 2020. The selected PHCs were from the different geographical distribution of the city: one from north, south, west, and east.

Inclusion and exclusion criteria

Inclusion criteria included all children aged under 5 years who attended the four chosen PHCs in Erbil city. Exclusion criteria included infants <6 months of age.

Data collection and measures

The data were collected from the mothers and recorded in a predesigned questionnaire been prepared by the researcher through proper utilization of relevant literature. The questionnaire was separated into three following parts:

Part I

The first part covered the following sociodemographic variables: age, gender, residence, mother work, and mother educational level, and socioeconomic status of the family estimated by education and occupation of the father with private car and own house.

Part II

The nutritional information was recorded in the second part of the study. The information was immunization history, breastfeeding, milk type, amount of milk, complimentary food, eating vitamins, using appetizer, and having any disease, consuming food based on the WHO recommendation. Other nutritional issues were bottle feeding, insufficient milk, improper intake of food, lack of active feeding, and not feeding well during illness.

Part III

The anthropometric measures and the presence of anemia were recorded in the third part of the questionnaire.

The weight and height were measured in kg and cm, respectively. The body mass index (BMI) of the children was evaluated based on the Z-scores. The Z-scores between −2 and +2 were considered normal weight, >+2 as overweight, and <−2 as underweight. The Z-scores were determined based on the growth charts of the WHO. The feeding problem was established as having one of the following criteria: eating complementary feed according to the WHO recommendations (amount: 1 cup = 250 ml and frequency: 3–4 main meals and 1–2 snacks), receiving quality or type of food according to the WHO recommendations, active feeding, or receiving serving by children.

The anemia was determined by either palmer or mucous membrane pallor or by done complete blood count.

Statistical analysis

The prevalence of feeding issues in children under 5 years was determined in number and percentage. The types of feeding problems were determined in number and percentage. The association of feeding problems with sociodemographic, BMI, and anemia was examined in Pearson's Chi-squared and Fisher's exact tests. P < 0.05 was considered a statistically significant difference. The statistical calculations were performed by the Statistical Package for the Social Sciences version 25 (SPSS, IBM Company, Chicago, IL 60606, USA).

Ethical considerations

The protocol of this study was approved by the Ethics Committee at the College of Medicine, Hawler Medical University, and an acceptance letter from the Directorate of Health of Erbil is obtained. The written consent form was taken from the mothers of all children before participation in the study.


  Results Top


The children who were included in this study aged 6–9 months (11.3%), 9–12 months (4.9%), 12–24 months (32.0%), and ≥24 months (51.7%) and were males (55.2%) and females (44.8%). They were from urban (88.2%) and rural areas (11.8%). Most of the children had medium (62.6%) and low socioeconomic status (35.0%). The majority of the mothers of the children were homemakers (93.0%) and had no official educational certificate (66.0%) [Table 1].
Table 1: General characteristics of the children and their parents

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The prevalence of complementary feeding was 49.5% in children and 88.5% received the adequate amount and frequency. More than half of the children had active feeding (54.2%) and 65.0 ate by themselves. In addition, 59.6% of the children receive adequate quality of food [Table 2].
Table 2: Frequency distribution of the World Health Organization criteria of feeding problems

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The study did not show a significant difference in complementary feeding, amount and frequency, quality, active feeding, and own serving between male and female children [Table 3].
Table 3: Association of the World Health Organization criteria of feeding problems by gender

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The study revealed that 58.0% and 18.0% of the children had multi-feeding and mono-feeding issues, respectively. Only 24.0% of the children had no feeding problems [Figure 1].
Figure 1: Prevalence of feeding problems

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The study showed that children of younger age were more likely to have feeding issues. The prevalence of issues was 91.30% (6–9 months), 100 (9–12 months), 81.54% (12–24 months), and 66.67% (≥24 months; P = 0.007) [Table 4].
Table 4: Association of sociodemographic characteristics of the child and the mother with children's feeding problems

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The study showed that children with anemia were more likely to have feeding issues (93.10%) compared to the children without anemia (62.93%; P < 0.001) [Table 5].
Table 5: Association of general characteristics of the children's feeding and health status by feeding problems

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The study did not find a significant difference in feeding issues between children with normal and abnormal anthropometric measures [Table 6].
Table 6: Association of anthropometric measures of the children by feeding problem

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  Discussion Top


This study showed a high prevalence of feeding problems in children under 5 years old. The feeding problems were significantly higher in younger children and those with anemia. The study showed that a considerable percentage of children do not adhere to the WHO criteria for feeding children.

A study conducted in 204 healthy children aged between 1 and 5 years of age revealed that 26.9% have feeding issues. The children with feeding issues were less likely to eat at their tables or the family table.[9] Tribble[10] conducted some interviews with women in the Sulaimani Governorate in Iraqi Kurdistan to understand the reasons behind initiate breastfeeding and formula use. She analyzed the data of the 2000 and 2011 Multiple Indicator Cluster Surveys as well. The study showed that being urban, wealthier, and more educated raised the probability of a mother to use infant formula. However, only increasing education and wealth were shown to associate with breastfeeding probability. There was a significant difference in the probability of using the formula in mothers among Iraqi governorates. For example, in 2000, Karbala (24.32%) had a lower probability of formula use and higher percentage points of breastfeeding (6.78%) compared to Sulaimani. The probability of breastfeeding and formula use has been decreased over the ensuing decade, respectively. The mothers reported that they breastfeed their children during stressful times and uses formula when working outside the home. Anyhow, the situation of breastfeeding and formula use must be examined within each governorate.[10]

A group of physicians developed a questionnaire and distributed randomly among doctors in the Middle East and North Africa. They aimed to assess knowledge and practices about complementary feeding, the impact of iron deficiency, and its prevention. The study showed that 39.0% of physicians do not adhere to the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines about complementary feedings.[11]

Anyhow, the situation of breastfeeding and formula use must be examined within each governorate. A research study conducted in this region showed that the mothers who breastfed exclusively have higher levels of postnatal self-efficacy compared to the mothers who use formula.[12] A cross-sectional study conducted in Saudi Arabia showed that low-income and less-educated women are more likely to breastfeed their infants.[13] The lower education could be an associated factor to not meet the WHO criteria in this study, because majority of the mothers were not officially educated in this investigation.

The present study showed that a considerable percentage of children are formula users. The United Nations Children's Fund has recommended breastfeeding up to 2 years of age and beyond to increase survival. The breastfeeding must be started within 1 h of birth and exclusively for the first 6 months of life and continue to be breastfed up to 2 years of age and beyond. The breastfeeding should be combined with safe, age-suitable feeding of solid, semi-solid, and soft foods.[14]

The family system surrounding child life has a crucial role in establishing and promoting behaviors that persist throughout the child's life. The early-life experiences with different tastes and flavors have an important role in promoting healthy eating in future life.[15] Parental food habits and feeding are the important dominant factors of a child's eating behavior and food choices.[15]

A study conducted in Saud Arabia showed that 95.6% of mothers start breastfeeding and 59.8% initiate breastfeeding within the 1st h. Exclusive breastfeeding among infants aged 0–6 months is 44.3%. The median duration of breastfeeding and exclusive breastfeeding is 12 and 3 months, respectively. In addition, only 21.7% received the first complementary feeding at 6 months of age.[16]

It seems that feeding issues in children are associated with parents' and physicians' knowledge and practice rather than other sociodemographic aspects. Therefore, the educational services and better training of the physicians are suitable strategies to reduce the feeding issues of preschool children.


  Conclusions Top


The present study showed that a considerable percentage of children have feeding issues. The feeding issues were higher in younger age groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Santé Omdl, World Health Organization, Staff WHO, UNICEF., UNAIDS. Global Strategy for Infant and Young Child Feeding. WHO Website: World Health Organization; 2003.  Back to cited text no. 1
    
2.
World Health Organization. Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition. Geneva, Switzerland: World Health Organization; 2013.  Back to cited text no. 2
    
3.
Abeshu MA, Lelisa A, Geleta B. Complementary feeding: review of recommendations, feeding practices, and adequacy of homemade complementary food preparations in developing countries-lessons from Ethiopia. Front Nutrit 2016;3:41.  Back to cited text no. 3
    
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Burdette HL, Whitaker RC, Hall WC, Daniels SR. Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age. Am J Clin Nutr 2006;83:550-8.  Back to cited text no. 4
    
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Dewey KG. Increasing iron intake of children through complementary foods. Food Nutr Bull 2007;28:S595-609.  Back to cited text no. 5
    
6.
UNICEF. The State of the World's Children 2019 Children, food and Nutrition Growing Well in a Changing World (The State of the World's Children). New York Hentet fra UNICEF; 2019. Available from: https://www unicef org/media/60806/file/SOWC-2019 pdf. [Las accessed 20 Jun 2020].  Back to cited text no. 6
    
7.
World Health Organization. Infant and Young Child Feeding. WHO website: World Health Organization; 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/279517/A71_R9-en.pdf?sequence=1&isAllowed=y. [Last accessed on 20 Sep 2020].  Back to cited text no. 7
    
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Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet 2016;387:475-90.  Back to cited text no. 8
    
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Benjasuwantep B, Chaithirayanon S, Eiamudomkan M. Feeding problems in healthy young children: Prevalence, related factors and feeding practices. Pediatr Rep 2013;5:38-42.  Back to cited text no. 9
    
10.
Tribble AG. Comparing iraqi regional differences on infant feeding through breastfeeding and formula. Kurdistan J Appl Res 2018;3:7-14.  Back to cited text no. 10
    
11.
Lifschitz CH, Miqdady M, Indrio F, Haddad J, Tawfik E, AbdelHak A, et al. Practices of introduction of complementary feeding and iron deficiency prevention in the middle east and north africa. J Pediatr Gastroenterol Nutr 2018;67:538-42.  Back to cited text no. 11
    
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Piro SS, Ahmed HM. Impacts of antenatal nursing interventions on mothers' breastfeeding self-efficacy: An experimental study. BMC Pregnancy Childbirth 2020;20:19.  Back to cited text no. 12
    
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Amin T, Hablas H, Al Qader AA. Determinants of initiation and exclusivity of breastfeeding in al hassa, saudi arabia. Breastfeed Med 2011;6:59-68.  Back to cited text no. 13
    
14.
UNICEF. Infant and Young Child Feeding. UNICEF; 2019. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/; [Last accessed on 20 Sep 2020].  Back to cited text no. 14
    
15.
Scaglioni S, De Cosmi V, Ciappolino V, Parazzini F, Brambilla P, Agostoni C, et al. Factors influencing children's eating behaviours. Nutrients 2018;10:706.  Back to cited text no. 15
    
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Taha Z, Garemo M, Nanda J. Patterns of breastfeeding practices among infants and young children in abu dhabi, united arab emirates. Int Breastfeed J 2018;13:48.  Back to cited text no. 16
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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