The global focus on a 1 000 days from conception to 2 years stresses the importance this period has on improving infant health. South Africa has focused on policies and actions to improve breastfeeding rates but specific attention to complementary feeding practices is still lacking. The 2016 South African Demographic and Health Survey indicated an increase in stunting from 8 to 23 months of age – further highlighting the complementary feeding phase as a vulnerable stage for infants. Disaggregated local data on infant feeding practices is required to better inform decision makers on the current infant feeding situation before interventions can be considered.
The objectives of this PhD study were to review the current complementary feeding practices in South Africa; to describe and assess the infant feeding practices of 6-11 month-old infants attending the KwaMashu Community Health Centre in KwaZulu-Natal, South Africa; to use Optifoods software to ascertain if infant nutrient requirements can be met with a food-based approach, as well as to identify the nutrients that are difficult to achieve adequate intakes of; and to describe the main influences on mothers’ complementary feeding decisions.
A review of complementary feeding practices in South Africa (CHAPTER 1), revealed that despite updated infant feeding policies, in reality, poor infant feeding practices still prevail. In general, foods and liquids are introduced too early. Poor dietary diversity is of major concern.
A cross-sectional survey was conducted with mothers and caregivers from the KwaMashu Community Health Centre (CHAPTER 2) to determine the infant feeding practices of 6-11 month-old infants attending the well-baby clinic. One hundred and thirty-four interviews were completed with mothers/caregivers. 80.6% of infants were breastfed, with 63.5% of mothers/caregivers reporting breastfeeding initiation in the first hour after birth. Only 25.4% of mothers/caregivers reported exclusively breastfeeding to the age of 6 months. Almost a third of infants (30.6%) had started solid foods before 3 months of age. Cereals were the main first foods given, with 56.7% of caregivers preparing foods at home and 43.3% using commercial foods. At the time of data collection, 36.6% of the 6-11 month-old infants were breastfeeding, 47.0% were formula feeding and 16.4% received mixed feeding. Soft maize meal porridge and commercial infant cereals were the most popular foods consumed daily. Close to two-thirds of infants (64.9%) had at least one meat food group item and just over two-thirds of infants (68.7%) had eaten eggs in the previous 7 days. It is concerning that just over half of the infants (52.2%) were being given biscuits, two-thirds (66.4%) ate chips, and close to a third (32.8%) consumed sweets or chocolates.
The information from the 134 interviews conducted provided the food consumption input for the model using Optifoods software (CHAPTER 3). The objective was to determine if the nutrient requirements of 6-11 month-old infants can be met with a food-based approach, as well as to identify the nutrients that are difficult to achieve adequate intakes of. The results from the modelling exercise revealed that with the current food pattern of infants from the study group in KwaMashu, iron, zinc, and calcium were identified as the nutrients whose requirements are likely not to be met in the diet of these infants (nutrients of concern). The percentage RNI (Recommended Nutrient Intake) for iron was 25.2%, zinc 51.3% and calcium 77%. Nutrient intakes for these nutrients of concern improved in the “No pattern” diet but iron and zinc intakes still remained below the RNI. According to the best diets modelled by Optifoods, it appears that infants in KwaMashu would be able to achieve the recommended intakes of energy and protein, as well as the desired nutrient intakes for 8 of the 11 micronutrients as long as breastfeeding on demand continues during the complementary feeding phase.
In efforts to improve infant feeding practices, knowing what foods infants are currently consuming is important. However, it is equally important to understand why caregivers make certain complementary feeding choices and to identify what influences their behaviour when feeding infants in their care. Four focus group discussions with a total of 19 mothers were held at the KwaMashu Community Health Centre to try to understand some of the factors that affect the infant feeding decisions of mothers more clearly (CHAPTER 4). Mothers in KwaMashu seem to be aware which foods they should provide to their infants, but guidance to them on the frequency of feeding and the amount of food that should be fed to infants was absent. Despite being informed by the clinic and mothers knowing that 6 months was the correct age to introduce the baby to foods, they were uncertain about the age at which foods should be introduced. This matter regarding the age of food introduction is further complicated by the immense societal pressure, in particular from grandmothers in the household, to introduce foods earlier at a much younger age.
There are many issues associated with the complementary feeding diets of infants that need attention. The findings of this study call into question the continued food-based focus that is used to ensure nutrient adequacy in infants. In conjunction with efforts to improve household food security and the continued support and promotion of breastfeeding for the first 2 years of life, targeted micronutrient supplementation may be needed to ensure the optimal growth and development of infants in South Africa. The availability of new tools in nutrition, such as Optifoods, heralds an exciting phase in research and efforts need to be prioritised to train more people to use them and to make these tools available globally. To continue focussing infant nutrition education exclusively on mothers may not be a productive approach. The findings of this study support the inclusion of grandmothers (who in many cases may be the primary caregiver of infants) in education efforts to improve infant feeding practices.
Health facilities and provincial Departments of Health should review research findings from accredited research more systematically to make sure that they include these into their action plans. The South African government should consider an accessible repository dedicated to infant nutrition information. Infant feeding practices research requires active encouragement. It is essential for the dialogue between all stakeholders in the infant feeding field to continue with increased transparency and trust.