Feeding, care-giving and behaviour characteristics of undernourished children aged between 6 and 24 months in low income areas in Nairobi, Kenya

Childhood undernutrition remains a public health problem in slums in Nairobi, yet little is known about current childcare practices, particularly child eating and maternal feeding behavior and their impact on child growth. Treatment options for malnutrition in this setting involve the use of sweet, high energy ready to use foods (RUF), which have the potential to displace home foods, but few studies have assessed this. This thesis therefore aimed to quantify high-risk caring practices in children aged 6-24 months and how these vary with nutrition status. The effects of RUF on meal frequency and eating and feeding behavior were also assessed. The programme of research was underpinned by the following research questions: • What are the commonest modifiable risk factors for undernutrition found in children and how does this pattern vary with nutrition status? • Do ready to use foods displace complementary foods in moderately undernourished children? • Do ready to use foods affect eating and feeding behaviour? Preliminary studies were carried out to test the feasibility of using observations to assess childcare practices. Caregivers of children aged between 6 and 24 months were recruited in Wagha town, a semi urban area in Lahore, Pakistan and in selected slums in Nairobi, Kenya. A structured observation guide was used to collect information on caregiver child interactions during mid-morning meals in Pakistan and lunch time meals in Kenya. A description of childcare practices in the household, specifically dietary practices, feeding behaviour and hygiene practices were assessed by asking the following questions: Who feeds the child? How is the child fed? What is the child fed and how often? What are the hygiene practices of caregivers? Thirty meal observations, 11 in Pakistan and 19 in Kenya, were carried out in homes, while 11 meals were observed in day-care centres in Nairobi. Eating and feeding behaviours varied between cultures. Compared to caregivers in Kenya, caregivers in Pakistan offered more encouragement during meals. In Kenya, encouragement was mainly in response to food refusal and undernourished children were more likely to show aversive eating behaviour. Caregivers would respond to this behaviour by either restraining the child or simply leaving them alone. In day-care centres, laissez faire feeding was common as children were left to feed themselves with little or no assistance. Poor hygiene practices were also common, especially in Kenya where caregivers did not wash their hands before feeding their children. Meal observations were not representative as only one meal could be observed and they were also not practical because of insecurity in the slums. Based on these findings, a cross sectional study carried out in seven health facilities was designed. Caregivers of children aged 6-24 months were recruited from health facilities in two stages. In the first stage, undernourished children (weight for age or weight for length below - 2 Z scores or length for age below -3 Z scores) were quota sampled either from outpatient therapeutic or supplementary feeding programs based on severity and supplementation status between February and August 2015. Undernourished children were recruited from well-baby clinics during growth monitoring. Between July and August 2016 healthy children (weight for age above-2 Z scores) were also recruited from well-baby clinics at the same health facilities. For both groups, child anthropometric measurements were taken and information on sociodemographic, hygiene breastfeeding frequency, meal frequency, dietary diversity, child eating and caregiver feeding behaviour collected using a structured interview guide. Among children receiving ready to use foods, information on child interest in food, food refusal and caregiver force-feeding was also collected for both family meals and ready to use food meals. We recruited 415 children (54.5% female), over half (58.6%) of whom were undernourished. Caregivers and their children came from disadvantaged backgrounds characterized by low parental education. They also lacked access to basic hygiene and sanitation facilities. There was no association between nutrition status and hygiene as nearly all children came from households that lacked piped water (83.6%) and shared toilets (82.9%). Compared to healthy children, undernourished children were more likely not to be breastfeeding (undernourished 11.5%; healthy 5.2% P=0.002) and to receive plated meals at a low frequency (undernourished 12.2%; healthy 26.2% P=0.002). Diets offered were mainly carbohydrate based and there was no association between dietary diversity and nutrition status. Close to one third of children showed low interest in food 25.8% (107) and high food refusal 22.5% (93). Force-feeding was also relatively common 38.5% (155). Compared to healthy children, undernourished children were more likely to show low interest in food (undernourished 34.2%; healthy 14.0% P<0.001) and high food refusal (undernourished 30.9%; healthy 10.5% P<0.001); and their mothers were more likely to be anxious about feeding them (undernourished 20.6%; healthy 6.4% P<0.001). Within the undernourished group, 49.4% had either low interest in food or high food refusal or both. Force-feeding was common in both groups, with a non-significant trend towards more force-feeding in the undernourished infants (undernourished 41.4%; healthy 34.5% P=0.087). Children were more likely to be force-fed if they had low interest in food (odds ratio[95% CI] 3.72 [1.93 to 7.15] P<0.001) or high food refusal (4.83[2.38 to 9.78] P<0.001), after controlling for maternal anxiety and child nutrition status. Children appeared to prefer RUF to home foods which is good for treatment compliance, but it may have a negative impact on intake of home foods. Although a single sachet of RUF appeared not to displace family meals in moderately undernourished children, actual energy intake was not measured in this study and these findings are therefore inconclusive. Children in slum areas in Nairobi are exposed to many risk factors which puts them at risk of infection and undernutrition and provision of ready to use foods as a treatment option does not address the underlying problem. There is therefore a need for poverty alleviation strategies which will lead to improved access to hygiene facilities and better environmental conditions. Measures to improve access and utilization of safe nutritious foods as well as mother-child interactions during meals are also required. A better understanding of child care practices and underlying factors that influence them is also required for the design of effective and sustainable interventions in this setting.