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Community and International Nutrition

Poor Compliance with Appropriate Feeding Practices in Children under 2 y in Mexico¹

² Research Center on Nutrition and Health, and ³ Research Center on Population Health, National Institute of Public Health (INSP), Cuernavaca, Morelos, Mexico; and ⁴ National Institutes of Health, Mexico City, Mexico

^* To whom correspondence should be addressed. E-mail: jrivera{at}insp.mx.

	ABSTRACT

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
We evaluated breast-feeding and complementary feeding practices in Mexico, using data from a national probabilistic survey carried out in 17,716 households, with regional and urban-rural representation. Mothers of children <2 y old (n = 3,191) reported duration of breast-feeding and the ages of usual introduction of 7 food groups. The Kaplan-Meier method was used to estimate the median time of feeding events. Practices were analyzed by categories of ethnicity, housing condition, and place of residence (geographic region and degree of urbanization). We found that 86% of infants at 1 mo and 39% at 11 mo were breast-fed, whereas 60% at 1 mo and 8% at 6 mo were exclusively breast-fed. Early introduction (<6 mo) of water, nonhuman milk, nonnutritive liquids, and fruits and vegetables was reported for all categories studied. Also, early introduction of nutritive liquids, cereals and legumes, and animal foods other than milk occurred in all categories except rural areas and the indigenous population. Late introduction of solid foods was documented in large proportions of infants in rural areas and in poor families. Poorer, unemployed, and indigenous women, and those bearing males, had a significantly higher probability of feeding their infants as recommended by the WHO. Feeding practices were unrelated to attained growth when the influence of economic and social factors was considered. Results indicate the need to implement actions for the promotion of exclusive breast-feeding during the first 6 mo and of timely introduction of complementary foods thereafter.

	Introduction

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

The WHO recommends exclusive breast-feeding during the first 6 mo of life, followed by introduction of adequate complementary feeding (15). Breast-feeding is recommended for 2 y or more if the mother-child couple so desires.

Foods introduced prior to 6 mo of age displace breast milk intake while maintaining total energy consumption (16). There is therefore no nutritional advantage from introducing foods before 6 mo, given that the nutritional quality of mother's milk is superior to that of other foods. Furthermore, early introduction (<6 mo) of foods in developing countries is of particular concern due to its low energy and nutrient content and the risk of diarrhea caused by inadequate hygiene (1,3). On the other hand, late introduction (later than 6 mo of age) of complementary foods may be associated with deficient growth, because breast milk is no longer sufficient to satisfy nutritional needs after that age (17).

The objective of this paper is to describe infant feeding practices in Mexico, including breast-feeding and complementary feeding at the national level as well as in urban and rural areas, and to compare such practices with international recommendations.

	Materials and Methods

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
    1999 National Nutrition Survey. Between 1998 and 1999, a national, cross-sectional, probabilistic survey was carried out in Mexico. Its primary objective was to evaluate the nutritional status and food intake of children <12 y of age and of women between 12 and 49 y of age. Information was gathered from 17,716 households using multi-stage cluster sampling, which provided representative data for the national level, 4 regions (North, Center, Mexico City and metropolitan area, and South), rural areas (<2,500 inhabitants) and urban areas (2,500 inhabitants). The sampling framework and methodology have been described in detail in an earlier publication (18). The present analysis includes the data on children under 2 y of age.

Informed written consent was obtained from the adult participants and those responsible for the children's care. The study protocol was approved by the Committee on the Use of Human Subjects in Research of the National Institute of Public Health.

    Data collection and construction of indicators. Housing conditions and accumulated wealth information were used to build an index using the first component resulting from a principal components analysis (19). Only variables with a weight factor > 0.7 were maintained in the model. These included: floor material, availability of piped water, telephone service, and possession of certain goods including refrigerator, washing machine, stove, radio, television, video cassette recorder, and computer. The first component explained 56% of the total variance. The score resulting from the factor analysis is a continuous variable that was used as such in some analyses or divided in housing conditions tertiles (HCTs) in others.

Households that reported that any woman in the family between the ages of 12 and 49 spoke an indigenous language were classified as indigenous. Anthropometric measurements, age, and sex of the children studied were used to calculate Z scores for weight/age, height/age, and weight/height, in accordance with the international reference values proposed by the WHO (20).

Infant feeding practices, including maternal breast-feeding and introduction of complementary foods, were evaluated through a questionnaire given to households with children 0–23 mo of age. The informant in these households (generally the mother) was asked to indicate the age (mo) at which her 0–23-mo-old child regularly consumed at least 1 food from each of the following 7 food groups: 1) plain water, 2) nonhuman milk (formula or cow's milk), 3) nonnutritive liquids (sugared water and other water-based drinks such as tea, bean, or chicken broth, coffee, sodas, or aguamiel [liquid from the agave plant] but not fruit juices), 4) nutritive liquids (a maize drink with water or milk known as atole, other cereal drinks with water or milk, coffee with milk, and fruit juices), 5) cereals and legumes (pasta, rice, tortilla, bread, oatmeal, beans, lentils, and chick-peas), 6) fruits and vegetables, and 7) foods of animal origin except milk (meat, eggs, cheese, yogurt, etc.). If a particular food group had not been introduced regularly into the child's diet at the time of the survey, it was recorded as "not introduced regularly at that specific age." Also, the informant was asked whether the child had ever been breast-fed, if he/she was still breast-feeding at the time of the survey, or the age at weaning otherwise. The combination of the information on breast-feeding and on introduction of food groups was used to estimate the duration of exclusive breast-feeding, defined as the consumption of only human milk with no other liquid or solid food.

Infant's feeding practices during the first 10 mo of life (from birth to 9 mo of age) were evaluated among children between 10 and 23 mo of age at the time of the survey. The period between 0 and 9 mo allows appropriate evaluation of infant feeding practices (as shown below), while providing an adequate sample size of children who had already completed this age period (children 10–23 mo at the time of the survey).

Infant feeding practices during the first 10 mo of life (birth–9 mo of age) were considered to be as recommended if all of the following criteria were met at the time of the survey (Table 1): 1) breast-feeding, with or without consumption of water or nonnutritive liquids and without consumption of other milks during the entire period of birth to 9 mo; plus 2) no consumption of nutritive liquids, solid foods (cereals and legumes, fruits and vegetables, and animal products), and other milks from birth to 5 mo of age; plus 3) consumption from at least 1 group of solid foods (cereals and legumes, fruits and vegetables or animal food products except milk) with or without consumption of nutritive liquids from 6 to 9 mo of age. Infant feeding practices were also analyzed by 2 age subgroups: from birth to 5 mo, and from 6 to 9 mo.

    Statistical methods. The data were analyzed using the SVY module of STATA to account for the complex sampling design (21). The proportion of children who received human milk and foods from each food group at the national level at each age and by each one of the categories studied was estimated using the Kaplan-Meier Survival Analysis Method (22) weighted by the sample design. For plotting purposes, these values were smoothed and expressed as completed months. The statistical differences among the categories were estimated by Cox regression models, adjusting by the complex survey. If at the time of the survey a particular child was not yet consuming regularly any food from a food group or was still breast-feeding, this information was recorded and used as censored data during this survival analysis. The age at which 50% of the children regularly consumed 1 or more foods from a particular group was defined as the median age of introduction of that particular food group. The ages at which 50% of the children were breast-fed (regardless of consumption of other foods) or exclusively breast-fed, were considered as the median ages for duration of breast-feeding and exclusive breast-feeding, respectively.

For several variables, we tested the statistical difference between the 2 categories of infant feeding defined in Table 1, using the Pearson statistical test for categorical variables and the Wald statistical test for continuous variables (23).

To evaluate the determinants of feeding as recommended, logistic regression models for complex samples (24) were used. The independent variables were: location of residence (urban/rural), HCTs, ethnicity (if a woman 12–49 y speaks an indigenous language in the household, yes/no), mother's educational level (years completed), mother's paid employment outside home (yes/no), number of children in the family, whether the mother lived with her husband or partner (yes/no), and the sex of the child. The final model included only the variables that were statistically significant (P < 0.05).

Linear regression models were used with median Z scores (weight/age, height/age, and weight/height) as dependent variables and compliance with feeding recommendations as independent variables with and without adjustments for covariates and potentially confounding variables.

Data were entered using the Fox Pro (25) program and statistical analyses were carried out with STATA (version 9.0, 2005) (21). In general, P-values < 0.05 were considered statistically significant.

	Results

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
Information was obtained in 17,716 households, representing 82.4% of the 21,503 households identified in the sampling framework. The households in which information was not obtained were uninhabited (9.8%), not located (1.9%), or informants were either not found or not willing to participate (5.9%). A total of 3,197 children <2 y of age were identified in the surveyed households of which 3,191 without missing data were included in the analysis.

At the end of 1 mo of life, 42% of infants were exclusively breast-fed, followed by a marked decline, reaching values under 5% at the end of mo 5 (Fig. 1). The proportion of infants who were breast-fed (regardless of consumption of other foods) decreased from 86% at the end of the mo 1 to 39% at the end of 11 mo (Fig. 1).

View larger version (22K): [in this window] [in a new window]   Figure 1  Proportion of children between 0 and 23 mo of age regularly receiving foods from each food group. Kaplan-Meier life table estimates from recall data, adjusting for the complex design effect (smoothed curves).

The estimated ages at which 25, 50, and 75% of the infants were regularly consuming at least 1 food from each of the 7 food groups are presented in Figure 2A for liquids and Figure 2B for solids for several subgroups. Given the large sample sizes, almost all differences in the age of introduction among categories within food groups (Fig. 2) were significant (P < 0.05). The exception was differences between medium and high HCT for nonhuman milk and nutritive liquids (P < 0.1).

View larger version (19K): [in this window] [in a new window]   Figure 2  Age for regular consumption of liquids (A) and solid (B) foods in children between 0 and 23 mo. Kaplan Meier life table estimates form recall data are shown, adjusted for the complex design effect. Upper, central, and lower limits correspond to ages closest to the probabilities 0.25, 0.50, and 0.75, respectively.

Median age for introduction of plain water was 3 mo in all subgroups, except in the indigenous group, which did so 1 mo later (Fig. 2A). The median age for introduction of nonhuman milk was 3 mo in urban homes, nonindigenous households, and the mid HCT; 1 mo later (4 mo) in the rural areas; earlier (at 2 mo) in the upper HCT; and considerably later (6 and 7 mo) in the low HCT and indigenous households, respectively. Median age for introduction of nonnutritive liquids (broths, sugared water, and tea) was 3 mo, except in rural areas and the lower HCT, in which it occurred at 4 mo, and in the indigenous households, where 5 mo was the age of introduction of this food group. Nutritive liquids (atole, coffee with milk, fruit juices) were introduced at 5 mo in urban areas, nonindigenous, and middle HCT households, 1 mo earlier in the high HCT homes, and at 6 mo in the other categories, except for the high HCT group, where it occurred at 4 mo. Fruits and vegetables were introduced at a median age of 4 mo in urban, nonindigenous, and mid and upper HCT groups, at 5 mo in rural and low HCT households, and at 6 mo in indigenous households. Cereals and legumes were introduced at 5 or 6 mo in all categories, and animal-food products (except milk) were introduced at 6 mo in all groups, except indigenous households, where it occurred 1 mo later.

Analysis of the ages (in mo) corresponding approximately to the 0.25 and 0.75 probabilities of regular consumption of the different food groups illustrated that whereas a large percentage of infants (25%) regularly consumed some foods from birth, especially liquids, many (25%) also did not regularly consume any food item from the various food groups at ages at which they already should have (after 6 mo of age).

Noteworthy for its early introduction is plain water, which was consumed by 25% of infants from birth in all groups. This was followed by nonhuman milk, regularly consumed by one-fourth of infants from mo 1 of life in the urban, nonindigenous, and mid and upper HCT groups. Nonnutritive liquids were consumed regularly by one-fourth of infants in mo 2 and 3 of life in all groups except in indigenous households, in which it occurred at 3 mo.

At the other extreme, animal-food products (except milk) were not regularly consumed by one-fourth of the children at 9 mo in the most deprived populations: rural, indigenous, and low HCT households. Cereals and legumes were not regularly consumed at 7 mo by 25% or more of the infants in all groups. At 12 mo of age, one-fourth of children did not regularly consume nonhuman milk in rural areas, indigenous families, and the lower HCT group.

Infant feeding practices from birth to 9 mo of age were classified as recommended according to the definition in Table 1 in only 6.7% of children between 10 and 23 mo (n = 110), in 13.8% of children from 0 to 5 mo (n = 225), and in 21.7% in children from 6 to 9 mo (n = 353).

Simple comparisons of means and proportions (Table 2) showed that poorer housing condition scores, lower mother's education, residence in rural areas and in the South, being indigenous, and having a larger family were associated with infant feeding practices as recommended in the 3 age groups studied (P < 0.05).

	Discussion

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
The results of this study indicate that breast-feeding practices in Mexico are far from the WHO recommendations (15). Although 92.3% of children were breast-fed at birth, a sharp decline was observed, thereafter resulting in <40% of children breast-fed by their 1st birthday. Moreover, the median age of introduction of all food groups occurred before 6 mo of age, and therefore exclusive breast-feeding dropped from an already low 42% rate at 1 mo of age to under 5% by the 6 mo of age.

Although premature introduction of foods is relatively widespread, it is more frequent in families with better housing conditions, residence in urban areas, and in nonindigenous households. In contrast, late introduction of complementary foods is more common in rural areas and among poorer families and is particularly late in indigenous households.

Height for age Z scores were lower in infants with feeding practices classified as recommended than among those whose feeding practices were not as recommended. Poorer and indigenous mothers in Mexico exclusively breast-feed their infants more frequently and for a longer duration than the rest of the population (26,27); therefore, nutritional status comparisons were adjusted for indicators of poverty and indigenous background. The differences disappeared after this adjustment, indicating that the poorer growth among those with better feeding practices was explained by poorer living conditions and cultural rearing practices associated with indigenous background. The results clearly indicate that the groups that tend to comply with the exclusive breast-feeding criteria are the same ones that tend to delay introduction of some fundamental foods for satisfaction of nutritional needs after 6 mo of age and whose living conditions are worst.

The adverse health consequences expected from early complementary feeding include gastrointestinal and respiratory infections and delayed growth and cognitive development, and from early introduction of breast milk substitutes, increased future risk of obesity and chronic diseases (28,29). On the other hand, an important number of children received foods other than breast milk too late, resulting in a higher risk of delayed growth and undernutrition.

Maternal employment reduced the probability of both exclusive breast-feeding and timely introduction of complementary foods at ages 6–9 mo, even controlling for the strong influence of housing conditions, as has been reported in the literature (30–32).

The availability of data from birth to the current age of the child at the time of the interview allowed the use of recall information from all children-months, through the Kaplan-Meier methodology, which adjusts for truncated data. The status quo method (33) provides reliable estimates, because information is not biased by maternal recall but radically restricts the number of observations limiting the ability to make inferences for sample strata and subgroups, which are the primary objectives of this study. Besides sample size, another advantage of the recall method is its ability to identify foods already introduced in the infant's diet but not necessarily consumed on a daily basis. Due to a large day-to-day variability in infant food consumption, status quo data may underestimate habitual consumptions, especially for foods not consumed on a daily basis. Possible biases in the estimations due to the mother's recall are unlikely, because recall errors are probably random. Also, the possible variance increase due to random errors in the recall method is usually compensated for by larger sample sizes.

A particular case of potential bias in the estimation is data lumping around a preferred digit due to recall error. Our data shows evidence of data lumping at 6 mo. This may be either a true recall bias or may reflect an actual increase in the frequency of food introduction at 6 mo, which follows WHO recommendations. To evaluate potential recall bias, we took advantage of the fact that the 2, albeit not strictly comparable, sources of information (status quo and recall) were available for the same observations. Recall data estimate regular consumption, whereas status quo estimates what was consumed the day prior to the survey. Duration of breast-feeding was chosen to evaluate potential recall bias largely because it is unlikely that an infant who is breast-fed during a particular time will not receive breast milk during a given day in that period (for example, the day prior to the survey), particularly during the age of interest in this study (0–9 mo) and most probably s/he has been breast-fed since birth, reducing the potential misclassification. Duration of breast-feeding was obtained through both methods. Using the status quo method, we estimated the median duration at 9 mo, whereas the result was 8 mo using the recall method. These results indicate a small underestimation from the recall method used in this article in a magnitude that does not fundamentally modify the conclusions.

There were limitations derived from the data set used. The cross-sectional nature of the data precludes making causal inferences. Also, the implications of our study are limited by the lack of information on quantities of foods consumed and by the lack of specificity on foods consumed within each group. This is particularly important when attempting to evaluate the micronutrient nutritional status.

Even with these limitations, our results point to the urgent need to implement effective programs for improving infant feeding practices, particularly exclusive breast-feeding and timely introduction of appropriate complementary foods. The families with greatest need for promotion of exclusive breast-feeding are those living in urban areas and families from the upper HCT, although introduction of liquids and milk other than human milk is premature in all the strata studied. In the poorest population (indigenous families, rural areas, and the lower HCT), it is important to promote timely introduction of nutrient-rich solid foods (including animal-product foods other than milk) once the child reaches 6 mo of age to ensure optimum growth and child development.

This study identifies the determinants of infant feeding, but it is still necessary to study, through a mix of quantitative and qualitative techniques, the reasons for such feeding practices. Information is needed on the actors intervening in the maternal decision process (i.e. family members, health sector, and employment conditions) as to how, what, and when to feed her child, and on barriers and motivational elements for adopting the practices recommended by the WHO.

The design of adequate infant feeding promotion programs and policies is urgent given the problems documented and the potential benefits for children's health, survival, and cognitive development, as well as the many maternal health benefits, such as a decreased risk of breast cancer and a potential decrease in the risk of obesity.

	FOOTNOTES

 
¹ Supported by The Second National Nutrition Survey by the Mexican Ministry of Health and by the National Institute of Public Health (INSP).

Manuscript received 29 August 2005. Initial review completed 20 October 2005. Revision accepted 23 August 2006.

	LITERATURE CITED

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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by González-Cossío, T. Articles by Sepúlveda, J. Search for Related Content PubMed PubMed Citation Articles by González-Cossío, T. Articles by Sepúlveda, J.