Knowledge, attitudes and practices regarding infant feeding among mothers of children with severe acute malnutrition in the rural areas of Northern India

Introduction: Malnutrition has been identified as one of the principal causes limiting India’s global economic potential. The infant and young child-feeding practices determine the nutritional status, growth and ultimately the survival of infants and young children. The study aimed to assess the knowledge, attitude and practices of rural mothers with children diagnosed with severe acute malnutrition (SAM) regarding infant feeding. Methodology: A hospital-based cross-sectional descriptive study on 116 mothers from the rural area of Northern India with children diagnosed with SAM. Assessment of knowledge, attitude and practice of mothers regarding infant feeding was done through face to face interviews using a structured questionnaire containing 32 questions. Results : The mean age of admitted children was 14.48 ± 4.71 months. The majority of mothers (81.9%) studied till only primary school or were illiterate. The appropriate knowledge about early initiation of breastfeeding and the ideal time to start complementary feeding was found in 42.4% and 45.6% of mothers respectively which was suboptimal. The attitude towards ideal breastfeeding practices was positive in most mothers. However in practice only 59.4% of mothers exclusively breastfed their babies till 6 months and 54.3% delayed initiation of complementary feed beyond 9 months of age. The frequency of complementary feeding was inadequate in the 6-8 months age group as stated by 88.6% of mothers and minimum dietary diversity was not followed by 68.1% of mothers. Conclusion: The knowledge and positive attitude towards infant feeding are not applied in practice by mothers. Efforts should be made to improve knowledge, attitude and practice with an emphasis on complementary feeding indicators to reduce the burden of malnutrition in the rural population.67

Food and feeding behaviors in children are closely linked to and shaped by their family's preferences, practices and backgrounds [6]. Parents also may lack knowledge on appropriate foods and feeding practices for the child's age and have inadequate awareness and or means for proper caring and health-seeking which is a contributing factor leading to malnutrition in this age group. Addressing this problem of poor knowledge and poor adoption of appropriate child feeding practices can be one step closer towards reducing child undernutrition or child stunting thereby reducing under-five mortality.
With this background, authors conducted this study to find out the knowledge, attitude and prevailing practices among rural mothers of children with SAM regarding infant and young child feeding. Any gaps in knowledge and practices found during this study can be used to counsel the mother and other primary caregivers which will go a long way to improve the status of the severity of malnutrition in rural areas. Knowledge, attitude and practices of the mothers regarding infant feeding was studied.    More than 1 source of information *Data are expressed in percentage There was more than one source of information for most of the respondents.    Caesarean section, babies requiring admission, mother too tired to feed and less secretion of milk.

Material and Methods
The data in various studies in India show that initiation rates are variable from 16 to 54.5% [10].
Studies from developing countries like India, Pakistan, Bangladesh and Nepal indicated that higher maternal educational attainment in the total population was associated with EIBF compared to those with no schooling [11][12][13][14]. In our study majority of mothers (69.8 %) studied till only primary school and 12.1% were illiterate. This emphasizes the need for health professionals to make antenatal mothers more aware of the importance of initiation of early breastfeeding and providing facilities of rooming-in immediately after delivery.
Exclusive breastfeeding is recommended for the first six months of life which in turn leads to a reduction of early infant morbidity and mortality [8]. In the present study, the majority of mothers (81.9 %) knew about the importance of breastfeeding, however only 49 (42.2 %) knew about the appropriate duration of exclusive breastfeeding.
Majority of mothers had a positive attitude that exclusive breastfeeding (EBF) till 6 months is beneficial to the child. However in practice only 69 (59.4%) mothers exclusively breastfed their babies which is similar to CNN survey that reveals that only 58% of infants (0-5 months) were exclusively breastfed [3]. Our result was also comparable to surveys done in the rural population of our neighbouring states like Rajasthan (57.5%), Maharashtra (60.6%), and Madhya Pradesh (60.6%) [15]. The most common reason for discontinuation of EBF in the present study was insufficient breastmilk as reported by mothers followed by the perception that newborns require supplementation apart from breast milk to gain weight. Almost half of the mothers (51.7%) were not aware that frequent breastfeeding increases milk production. The benefits of breastfeeding should be emphasized during the initial antenatal visits to increase EBF rates among all mothers. Also mothers should be educated regarding techniques to increase breastmilk and that consistent and exclusive breastfeeding is critical for stimulating milk production [16].
WHO also recommends continued breastfeeding beyond the six months, along with the provision of nutritionally adequate and safe complementary foods. According to CNN survey, the majority (83%) of children aged 12-15 months continued to be breastfed at age one and a higher proportion of children residing in rural areas (85%) were breastfed at age one year, compared to children in urban areas (76%). This is in contrast with our study in a rural population where it was found that In a systemic review of majority Asian studies, the combined prevalence of breastfeeding up to two years of age or beyond was 33% with a trend towards an increase in prevalence in the past three decades, especially in South Asia [18] [19,20]. In our study, the majority of mothers, 54.31% delayed complementary feed after 9 months. Although only nearly half of mothers exclusively breastfed their child but still complementary feed (semi-solid diet) was delayed as most mothers were giving animal/packed milk. The most common reason for the delay was no knowledge, a child not accepting feeds, regurgitation/vomiting or the elderly of the family suggested for starting complementary feeding only after one year etc.
The three core indicators of minimum dietary diversity, minimum meal frequency, and minimum acceptable diet are recommended by the WHO to assess the quality of complementary feeding practices for children aged 6 to 23 months. In the present study, the majority 78 (67.2 %) of the mothers had incorrect knowledge about minimum meal frequency in a 6-8-month-old child, however 75 (64.7 %) mothers were aware of the frequency of breastfeeding as 3-4 times/day for 9-23 months child. In contrast, only 11.3% and 36.2% of infants in the age group of 6-8 and 9-23 months received WHO recommended frequency of 2-3 times/day and 3-4 times/day, respectively [ should be present in diet after 6 months of age and in practice also only 61 (52.6 %) mothers gave adequately diverse diet to their children. Until 6-11 months of age, complementary feed in infants comprised mostly of liquids (diluted dal/rice starch) in 52.5% of cases along with some solid (often biscuits) as stated by 27.5% of mothers. Studies have shown that dietary diversity scores generally improve with higher maternal education and household wealth [22].
In the present study lower maternal educational status may be the reason behind insufficient dietary diversity. Lack of awareness, ignorance of mothers and lack of motivation emerged as prime factors responsible for these faulty infant feeding practices in the present study. Although breastfeeding knowledge and attitude was good but it was not reflected in their practices. Also delayed initiation of complementary foods and inappropriate complementary feeding concerning lack of knowledge about quality, quantity and consistency and practice of insufficient dietary diversity can be a contributing factor of malnutrition in these children. This study points that complementary feeding remains a challenge to be addressed in the rural population of India, hence, stressing the need for intensive health educational programs which will in turn improve the nutritional status of these infants.
Also the auxiliary nurses and midwives which are the primary point of contact in rural areas should be sensitised about repeated interpersonal communication and to improve the frequency, method and quality of the counselling process. There were some limitations in this research. First, since this was a hospital-based analysis, the results cannot be generalized to the general population.
Second, since the study relied on answers given by the mother hence, the findings are subjected to recall bias.

Conclusion
The present study concludes that there is a discrepancy between knowledge and practices as adequate knowledge is not implemented in practice. Even though the government has been implementing several programmes for minimizing malnutrition, still the knowledge, attitude and practices of infant feeding among rural mothers are suboptimal. Improving the complementary feeding practices can serve as a major determinant in reducing the burden of malnutrition, in turn reducing infant mortality. Thus it is important to strengthen the public health education campaigns and to provide, repeated counselling and support to mothers and other family members regarding infant feeding with the ultimate goal of preventing malnutrition.

What this study adds
Knowledge and practices regarding complementary feeding are suboptimal in rural mothers. Although there is knowledge about breastfeeding its implementation in practice is inadequate which need to be addressed to prevent malnutrition.

Contributions
Both DV and SKS were involved in the planning of study, data collection, analysis and manuscript preparation. All authors approved the final version of the manuscript.