Monitoring Nutrition - Infants and Young Children
Food and Nutrition Security is an important aspect of sustainable livelihoods and is often seen as a first step towards poverty alleviation. Nutrition security is defined by adequate nutritional status of individuals. Adequate nutritional status is essential for children’s health and development. Globally it is estimated that under nutrition accounts for 45% of death of all children below five years of age. Under nutrition is also a major cause of disability preventing children who survive from reaching their full physical and intellectual potential. Together with adolescent girls and women of reproductive age, infants and young children are among the most vulnerable for under nutrition. It can be assumed that once the nutrition outcomes for these groups have been improved the nutritional status of the whole household has improved.
Child growth is internationally recognized as an important indicator of nutritional status and health in populations. The WHO1 promotes the use of the following indicators (based on anthropometric measurements) to define the nutritional status of children under 5 years of age:
- Underweight: proportion of children with weight for age < -2 standard deviations of the median WHO child growth standards.
- Stunting: proportion of children with height for age < -2 standard deviations of the median WHO child growth standards
- Wasting: proportion of children with weight for height < -2 standard deviations of the median WHO child growth standards.
- Overweight: proportion of children with weight for height > +2 standard deviations of the median WHO child growth standards.
Besides these indicators the level of anemia, vitamin A and Iodine deficiency are important indicators for the nutrition status of a population. All above indicators usually form part of National Demographic and Health Surveys2, which are managed by the public sector, based on large sample sizes and typically conducted about every 5 years, to allow comparisons over time. The results of these surveys are publicly available for almost every country and provide an important source of secondary data for problem and/or context analyses.
Given the complexity of taking anthropometric measurements as well as defining levels of vitamin A and hemoglobin (iron) in the blood, these type of indicators are in general not suitable for development programs. That’s why actors like WHO, FAO and the USAID supported FANTA project have worked on simple proxy indicators for global use in assessing the quality (micronutrient adequacy) of diets and appropriateness of feeding practices. Recent developments – including increased attention and funding for nutrition-sensitive interventions3 – have increased the demand for such indicators.
Indicators for assessing infant and young child feeding practices4
Simple, valid and reliable indicators are essential to track progress and guide investment to improve nutrition and health during the first two years of life. At international level a set of eight core indicators are recommended 5, which are commonly included in National Demographic and Health Surveys (DHS).
Below a selection of indicators is given that could be included in development programs with specific objectives in the area of nutrition improvement. The data could be used as part of the problem analysis and for measuring impact over time of specific interventions in the area of IYCF practices. Findings could be complemented and/or compared with national DHS data.
1. Early initiation of breastfeeding: Proportion of children aged 0-23 months who were put to the breast within 1 hour of birth
Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infection and reduces newborn mortality. It facilitates emotional bonding of the mother and the baby and has a positive impact on duration of exclusive breastfeeding.
2. Exclusive breastfeeding under 6 months: Proportion of infants 0 - 5 months of age who are exclusively breastfed
Exclusive breastfeeding for 6 months confers many benefits to the infant and the mother. Chief among these is the protective effect against gastrointestinal infections, which is observed not only in developing but also in industrialized countries. This risk of mortality due to diarrhea and other infections can increase many-fold in infants who are either partially breastfed or not breastfed at all. In the context of HIV, introducing other milks, foods or liquids significantly increases the risk of HIV transmission through breast milk, and reduces infant’s chances of HIV-free survival. For the mother, exclusive breastfeeding can delay return of fertility.
3. Introduction of solid, semi-solid or soft foods: proportion of infants aged 6-8 months who receive solid, semisolid or soft foods
Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk and complementary foods are necessary to meet energy and nutrient requirements. At about 6 months of age, an infant is also developmentally ready for other foods. If complementary foods are not introduced when a child has completed 6 months of age, or if they are given inappropriately, an infant’s growth may falter.
4. Minimum dietary diversity: proportion of children aged 6-23 months of age who receive foods from 4 or more food groups
Dietary diversity is a proxy for adequate micronutrient-density of foods. Dietary data from children 6 – 23 months of age in 10 developing country sites have shown that consumption of foods from at least 4 food groups on the previous day would mean that in most populations, the child had a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food.
- The construction of the 7 food group score is done as follows: for each of the 7 food groups a point is added if any food in the group is consumed during the previous day.
5. Minimum meal frequency: proportion of breastfed and non-breastfed children 6 – 23 months of age, who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children) the minimum number of times or more.
The number of meals that an infant or young child needs in a day depends on how much energy the child needs (and, if the child is breastfed, the amount of energy needs not met by breast milk), the amount that a child can eat at each meal, and the energy density of the food offered. On average breastfed infants 6 – 8 months old need 2-3 meals per day, while breastfed children 9-23 months needs 3-4 meals per day, with 1-2 additional snacks as desired. Children who are not breastfed should be given 1-2 cups of milk and 1-2 extra meals per day.
- WHO, Nutrition Landscape Information System (NLIS) Country profile indicators, interpretation guide, 2010
- USAID. The Demographic and Health Surveys Program.
- The Lancet. Maternal and Child Nutrition Series 2013.
- These indicators are used/recommended by WHO and UNICEF. The WHO Nutrition Landscape Information System (NLIS Country Profile) provides national level data on these indicators.
- WHO/UNICEF/IFPRI/UCDavis/FANTA/AED/USAID. Indicators for assessing infant and young child feeding practices. Part 3: Country Profiles. Geneva. World Health Organization, 2010.