Maternal hygiene and knowledge on complementary feeding during infancy and early childhood in Lahore, Pakistan

Objective: To assess practice and knowledge levels regarding complementary feeding among mothers of infants. Method: The analytical cross-sectional study was conducted in CMH Lahore Medical College & Institute of Dentistry, Cantonment, Lahore, Pakistan, from December 2021 to April 2022, and comprised mothers of children aged 6-24 months. Data was collected using a self-administered questionnaire exploring hygiene practices and knowledge related to complementary feeding. Data was analysed using SPSS 23. Results: Of the 117 mothers with mean age 38.5±27.3 years, 115(98.3%) were married and 97(82.9%) resided in urban settings. Among the infants, 70(59.8%) were aged 12-24 months, 55(47%) were first-born, 72(61.5%) were exclusively breastfed for the first 6 months and 45(38.5%) continued breastfeeding along with complementary feeding after 6 months. Hygiene practices correlated to both marital status and the type of family (p<0.05). A significant association was found between mother’s occupation to breastfeeding and hygiene practices (p<0.05). There was no significant association of breastfeeding practices with maternal age and maternal education (p>0.05). Conclusion: Maternal information related to complementary feeding was found to be good, and breastfeeding practices were significantly associated with the mother’s occupation. Maternal hygiene practices were also good, and were significantly associated with the mother’s occupation and type of family.


Introduction
The optimal development of infants is dependent upon the way they have been fed different kinds of foods in their early lives.Complementary feeding is the process of introducing liquid and semi-solid foods of various kinds to meet the growing nutritive requirements of the infant which, as time passes, breastfeeding alone cannot fulfil. 1 According to World Health Organisation (WHO), complementary feeding should be appropriate, must have appropriate texture, have variety and be in sufficient quantities, and should be adequate and nutritive enough to meet the growing needs of a child.Complementary feeding should be started from 6 months onwards. 2 Irrelevant complementary feeding practices can result in more than one problems, such as stunting, delay in motor and mental development, neurological and mental fatigue, diarrhoea, loss of micro-nutrients and macronutrients, and malnutrition. 3In most countries, the majority of the decline in length-for-age during the first two years of life occurs during the complementary feeding period between 6 and 23 months of age. 4 Infant and child mortality rates in Pakistan are among the highest in the world at 53 infant deaths and 63 deaths under 5 per 1000 live births in 2023.5 Rural areas have a high burden of malnutrition in comparison to the urban areas, with a 6% higher underweight rate, 2.4% higher stunting rate and 3.4% higher prevalence of wasting. 6 has been proven through evidence that maternal education is linked with the timely introduction of complementary feeding, meal frequency, dietary diversity, and the practice of a minimum acceptable diet. 7he erstwhile Federally Administered Tribal Areas (FATA) in Pakistan represented the worst nutrition situation, as reported in the National Nutrition Survey (NNS) 2011, according to which, stunting rate among under-5 children was 58%, indicating poor economic conditions and food insecurity in the region.Early complementary feeding is found to be associated with various gastrointestinal (GI) infections, and late introduction beyond the age of 6 months may lead to iron deficiency anaemia. 8Dietary diversity is closely associated with socioeconomic and demographic characteristics as is the case with Pakistan where myths abound, such as certain nutritious foods being harmful to the infants,. 9ong children living in low-income settings, diarrhoea has been linked with unsanitary complementary feeding practices, including contaminated food preparation and storage environment, such as the method of washing utensils, use of contaminated utensils, poor storage of food and utensils, presence of animals in food preparation areas, lack of hand washing at crucial times that is before food preparation and child feeding. 10To make improvements, it is important to identify and address hurdles in accessing and consuming nutrientdense foods.Interventions to enhance complementary feeding practices and the dietary fine of complementary meals ought to bear in mind the contextual and proximal determinants of stunting.Effective Infant and Young Child Feeding (ICYF) practices are well-developed, primarily focussing on promoting breastfeeding plans to promote complementary feeding and encouraging strategies to improve family and community nutrition.Further, interventions have proven to improve ICYF practices. 11In order to attain the best outcomes nationally, these interventions must be supported by government policies.
The current study was planned to assess practice and knowledge levels regarding complementary feeding among mothers of infants.

Subjects and Methods
The descriptive, cross-sectional study was conducted in Lahore, Pakistan, from December 2021 to April 2022 after receiving ethical approval.The sample was raised using non-random convenience sampling technique.from the general population.Those included were Lahore-based mothers having at least one child aged 6-24 months.Mothers of babies with low birthweight (LBW), premature babies and babies having congenital deformities were excluded.
After taking informed consent from the subjects, data was collected using Google Forms, with the survey questionnaire consisting of structured, closed-ended questions.The questionnaire was designed in the light of WHO guidelines and was modified according to the target population 12 .
The questionnaire asked the mothers to fill the survey for their most recent child aged at least 6 months.The first component of the questionnaire was about the sociodemographic profile of the participants.The second section explored maternal knowledge on complementary feeding, and breastfeeding practices.The third section contained maternal hygiene practices related to preparation and storage of complementary food for the infants.
The sample size was calculated using Cochran formula with 5% margin of error and 95% confidence interval (CI) with assumed prevalence of 50% 13 .Data was analysed using SPSS 23.Frequencies and percentages were used for categorical variables, and mean and standard deviation for quantitative variables.Chi-square test was used to assess the significance of association between independent and dependent variables.P<0.05 was considered significant.

Discussion
Adequate nutrition in children aged 6-24 months is required for ensuring their healthy growth and development.Globally, 45% of mortality of children under-5 is due to malnutrition, 12 with Pakistan having some highly negative rates of malnutrition in comparison with other developing countries. 13A study in the United States found that adherence to recommended complementary feeding practices becomes associated with a higher nutritional repute in children with a decreased occurrence of malnutrition. 14This indicates the necessity of assessing maternal complementary feeding knowledge and hygiene practices in Pakistan.Such a research was not conducted in the Pakistani city of Lahore, which, to our knowledge, makes the current study novel.
A majority of the mothers (51.3%) had started complementary feeding at the optimal age of 6 months.The result is comparatively lower than a previous study in Ethiopia. 15There was a large proportion (41.9%) of mothers who initiated early complementary feeding before 6 months, which has been found in previous research in Nigeria as well. 16A study in the Netherlands proposed various factors associated with inappropriate complementary feeding 17 .The current research found that complementary feeding initiation was nonsignificantly associated with the type of family.Early complementary feeding before 6 months was associated with an increased risk for infections as well as stunting and wasting. 8For that reason, the high occurrence of early initiation of complementary feeding illustrated a requirement for interventions to teach mothers to improve their complementary feeding practices.
The current study found a significant association of breastfeeding practices with mothers' employment and marital status.This is consistent with previous findings. 18ygiene practices also showed a significant association with the mother's occupation and the type of family, which suggests children belonging to joint families have better hygiene practices. 19However, maternal education did not show any significant relationship with breastfeeding or hygiene practices, which is inconsistent with earlier findings. 20This could be due to the high ratio (43.6%) of mothers with higher education in the current sample.
Mothers who gave their children adequate portions of food rich in various nutrients was high (76.1%) in the current study, which is a positive indicator for preventing iron deficiency during the first two years of life. 21e study showed that 61.5% mothers did not continue breastfeeding with complementary feeding, which is lower than findings previously observed in Pakistan. 22his is substantiated by a study in South Asia which found uneven progress in breastfeeding practices trends, and highlighted Pakistan as one of two countries of particular concern. 23though the majority (65%) of mothers correctly knew that their child should be given more food after illness, inappropriate complementary feeding by mothers during and after an illness were observed in the current study.A large proportion (43.6%) of mothers were opting for less frequent breastfeeding during and after illness, and 53.8% mothers said they would switch to a fluid-only diet during and after an illness.This is in line with a previous study in South Asia 24 which found less than optimal feeding practices during and after an illness.This incorrect maternal practice could be due to inadequate information about the needs of sick children, and a lack of appropriate counselling from professionals.This asserts the need of providing mothers with correct and timely information on feeding during and after an illness.
As the intake of complementary foods increases, observing good hygiene practices is crucial for the prevention of GI illnesses.A majority of mothers had good hygiene practices in washing hands before food preparation, using clean utensils to prepare and serve food, treating drinking water, washing hands before eating, and using soap to wash hands.However, only 76% mothers indicated they washed their hands after defecation, which is lower compared to 97% reported by a previous study in Pakistan. 25This could be due to a lack of health education, and interventions like targeted training to increase the adoption of recommended hygiene practices of mothers can prove helpful.
The relationship between maternal hygiene practices and the immunisation status of a child proved non-significant.This is likely because the incidence of diarrhoeal disease in the child would be the variable affecting both these factors, as indicated by a study in Ethiopia that found a lower incidence of diarrhoeal disease in children who were fully vaccinated. 26Therefore, the current study indicated the need to account for the medical history of the child in place of recent illnesses and prior hospital admissions.
The current study had some limitations, as it did not take into account anthropometric measurements of the child for the determination of nutritional status, and for association with minimum meal frequency and diversity.Also, the majority of respondents were residing in urban areas, which did not allow it to compare rural and urban areas.
Despite the limitations, however, the current study was able to accumulate important information about the prevalence of good knowledge of complementary feeding and good hygiene practices among mothers.It also highlighted the need for targeted training for mothers on certain hygiene practices, such as washing hands after defecation, as well as educating mothers on breastfeeding practices, and feeding practices during and after an illness.As the majority of respondents in the study (47%) had first-born children, future studies are recommended to explore a potential decline or improvement of complementary feeding practices and maternal hygiene practices with children of higher birth order.Overall, it is recommended to give continued priority to the development of complementary feeding practice modules to bring about improvements in maternal knowledge in Lahore.

Conclusion
Maternal information related to complementary feeding was found to be good, and breastfeeding practices were significantly associated with the mother's occupation.Maternal hygiene practices were also good, and were significantly associated with the mother's occupation and type of family.

Table - 2
: Maternal hygiene practices and knowledge regarding complementary feeding.

Table - 3
: Association of variables with hygiene practices and breastfeeding regarding complementary feeding.