Abstract
India suffers a significant proportion of the global burden of childhood stunting and the prevalence of anaemia is a severe public health concern (i.e., > 40%). However, there is a lack of detailed information in India on infant and young child feeding (IYCF) and caring practices and whether micronutrient deficiencies contribute to the prevalence of anaemia during the complementary feeding period (6-23 months). This is unfortunate because children are particularly susceptible to growth faltering, micronutrient deficiencies, and infectious illnesses during this time. Clearly, there is a need for interventions to improve the nutritional status and health of Indian children during this vulnerable period.
This cross-sectional survey was conducted in 120 children aged 12-23 months living in low income households in a slum area of South Delhi, India. Trained research assistants administered a household questionnaire to mothers or primary caregivers and assessed child growth via anthropometry. Two days of in-home dietary data were collected in a subset of children (n=69) using weighed and recall methods to assess the number of children meeting select IYCF indicators. Non-fasting venipuncture blood samples were collected from a subset of the children (n=77) and biomarkers of haemoglobin, iron, zinc, vitamin A, folate, vitamin B12, vitamin D, selenium, and inflammation were measured to explore how micronutrient status contributed to the prevalence of anaemia.
Our results show evidence of poor nutritional status with 39% of the toddlers being stunted. More than 30% of toddlers had reports of recent symptoms of morbidity and had elevated markers of inflammation, multiple-micronutrient deficiencies were common, and almost 80% were anaemic. In addition, IYCF and caring practices were inappropriate. Early breastfeeding practices based on maternal self-report were poor, with approximately two-thirds of children reportedly initiating complementary feeding at six months of age. Further, only 55% of children were fed by a responsive caregiver and <40% fed their child appropriately during and after illness. The majority of children (88%) achieved minimum meal frequency (MMF; ≥ 3-4 meals per day), although only one-half (52%) of the children consumed complementary diets with a minimum dietary diversity (MDD; ≥ 4 food groups), with less than half (44%) achieving a minimum acceptable diet (MAD). Grains, roots, and legumes comprised the staple foods, although there was also frequent consumption (i.e., >60%) of high-sugar foods and savoury snack products. Consumption of vitamin A-rich fruits and vegetables, eggs, flesh foods and iron-fortified foods was limited and of concern. Such inadequacies in the complementary diets may have been responsible, at least in part, for the high prevalence (i.e., 74%) of at least two concurrent micronutrient deficiencies apparent among the toddlers. Of the micronutrient deficiencies, iron and vitamin D deficiencies were the most common (>70%) in these toddlers, followed by folate (37%), vitamin B12 (29%), zinc (25%), and vitamin A (17%), with the notable absence of selenium deficiency. Iron status was the only nutritional factor statistically significantly associated with haemoglobin concentrations and anaemia in these children in a multivariate analysis.
In conclusion, the inappropriate complementary feeding practices of these children is concerning and urgent action is required to address the high prevalence of anaemia and existence of multiple micronutrient deficiencies. Despite current supplementation programs in India, micronutrient deficiencies are still prevalent in this group of toddlers. We suggest that local health workers are trained to improve implementation of these programs, and that micronutrient powders are introduced to fortify complementary foods as an additional component of the existing Integrated Child Development Services (ICDS) to improve iron and vitamin D status of these children. An education program for mothers that includes messages on appropriate complementary foods, responsive feeding, and hygiene practices would also be beneficial.