
==== Front
BMC Pediatr
BMC Pediatr
BMC Pediatrics
1471-2431
BioMed Central London

39251977
5040
10.1186/s12887-024-05040-2
Research
Inappropriate complementary feeding practice and associated factors among children aged 6–23 months in Shashemene, Southern Ethiopia: a community-based cross-sectional study
Ayu Ermias Girma 1
Gemebo Tsegaye Demissie 1
Nane Debritu 1
Kuche Abel Daniel 2
Dake Samson Kastro tasamsona@gmail.com

1
1 https://ror.org/0106a2j17 grid.494633.f 0000 0004 4901 9060 College of Health Sciences and Medicine, School of Public Health, Department of Reproductive Health and Human Nutrition, Wolaita Sodo University, Wolaita Sodo, Ethiopia
2 https://ror.org/0106a2j17 grid.494633.f 0000 0004 4901 9060 College of Health Science and Medicine, School of Medicine, Department of Pediatrics and Critical Care, Wolaita Sodo University, Wolaita Sodo, Ethiopia
10 9 2024
10 9 2024
2024
24 57316 10 2023
28 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Inappropriate complementary feeding is widely practiced in low and middle income countries. These contribute to undernutrition, morbidity and mortality among young children. The incidence of malnutrition in the first two years of life has been directly linked with inappropriate complementary feeding practices along with high infectious disease levels.

Objective

To assess the level of inappropriate complementary feeding practice and associated factors among children aged 6 to 23 months in Shashemene, Southern Ethiopia.

Method

A community-based cross-sectional study was conducted from July to August 2021 among 609 children aged 6 to 23 months paired with their caregivers. Systematic random sampling was used to identify study participants. Data were analyzed by using SPSS version 25 software. Binary logistic regression analysis was used to identify predictors of inappropriate complementary feeding practice. Statistical significance was determined using Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI).

Results

The prevalence of inappropriate complementary feeding practice among children aged 6–23 months was 55.3%. Being a mother under the age of 25 years [AOR = 2.07, 95% CI: 1.30, 3.31], aged 25–34 years [AOR = 1.82, 95% CI: 1.14, 2.91], having an occupation [AOR = 2.73, 95% CI: 1.84, 4.05], and households where husbands’ are the sole decision makers on their income [AOR = 2.41, 95% CI: 1.54, 3.77] increased the chance of inappropriate complementary feeding practice. On the other hand, mother’s whose infants were aged 9–11 months [AOR = 0.30, 95% CI: 0.19–0.45] were less likely to practice inappropriate complementary feeding.

Conclusions

The prevalence of inappropriate complementary feeding practice in the study area was high compared to the WHO recommendation. Child’s age, maternal age, maternal occupation, and decision-making role on income were found to be associated with inappropriate complementary feeding practice. Appropriate behavioral change communication to family and community decision-makers, and involvement of husbands in infant and young child feeding practice are recommendable.

Keywords

Complementary feeding practice
Children
Undernutrition
Ethiopia
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

The period from birth to two years of age is a “critical window” for the advancement of ideal development, wellbeing and improvement, which are straightforwardly subject to nourishment. The World Health Organization (WHO) recommends to exclusively breast-feed till six months of age, and to start complementary feeding at six months while continuing breast-feeding up to two years or beyond [1].

Complementary feeding is the process of starting other foods and liquids in addition to breast milk since breast milk alone is not sufficient to meet the nutritional requirements of infants after six months of age [2]. Complementary feeding is considered as inappropriate when it fails to fulfill either timely introduction of complementary feeding, minimum dietary diversity or minimum meal frequency [2, 3].

Inappropriate complementary feeding is associated with a higher risk of undernutrition and mortality [4, 5]. Children who develop undernutrition early in their life are in turn at increased risk of developing long lasting effects on physical and cognitive growth during adulthood [6]. Children who take inappropriate complementary feeding will also develop diseases like diarrhea and tract infections, and end up in micronutrient deficiency and growth failure [7].

Globally, 13% of deaths of children aged less than 5 years could be prevented with optimal breast-feeding and additional 6% reduction could be achieved with appropriate complementary feeding practices [8]. Poor adherence to the World Health Organization (WHO) and infant and young child feeding (IYCF) guidelines may increase the risk of respiratory and other infections [9]. Infants develop more respiratory illness and eczema if complementary feeding is started before 6 months of age [10]. In addition, if complementary foods are not introduced around the age of six months, or if they are given inappropriately, it leads to growth faltering in infants [11].

According to the Ethiopian Health and Demographic Survey (EDHS) report, timely introduction of complementary feeding, dietary diversity and minimum meal frequency were 69%, 14% and 55% respectively [12]. In South Nations and Nationalities Peoples Region, only 2.5% of infants and young children meet minimum dietary diversity and only 2.3% of them had the minimum acceptable diet [13]. Even though different efforts were made by government to reduce inappropriate complementary feeding practices through creating and implementing IYCF practices and nutrition actions, the prevalence is still higher.

However, there is a scarcity of evidence on inappropriate complementary feeding practices and associated factors since most of the previous studies assessed the predictors of appropriate complementary feeding rather than inappropriate complementary feeding practice (ICFP). This study aimed to assess inappropriate complementary feeding practices and associated factors among children aged 6–23 months in Shashemene, Southern Ethiopia. The results of this study could help nutrition programmers develop appropriate strategies to prevent ICFP and enhance complementary feeding practices in the study area. The findings of this study can be used as an input by policymakers, program managers, health service providers, and other stakeholder that contribute to improving IYCF in Ethiopia.

Methods

Study setting

This study was conducted in Shashemene town, Southern Ethiopia. The town is located 255 km South from Addis Ababa, the capital city of Ethiopia. There are eight kebeles (lowest administrative unit) in the town. The town has 286,477 residents; 144,484 men and 141,963 women. The number of children aged 6 to 23 months in the town is 12,260. In the town, there are two public and one private hospitals, four public and one private health facilities, 61 clinics, and 59 pharmacies.

Study design and study period

A community-based cross-sectional study was conducted from July 1 to August 15 in 2021.

Population

All children aged 6 to 23 months paired with their mothers/primary care givers were the source population. Selected children between 6 and 23 months of age paired with their mothers/primary care givers who lived in the town for at least 6 months were studied. Infants and young children whose usual feeding pattern was changed due to an illness that can affect their appetite during the study period were excluded from the study.

Sample size and sampling procedure

The sample size was determined by using assumptions of single population proportion formula in Epi Info software version 7.0 assuming 50.6% prevalence of ICFP [14], 95% confidence level, 5% margin of error, 1.5 design effect, and 10% non-response rate. The final sample size comprised 634 children aged 6 to 23 months paired with their mothers or primary caregivers. Three kebeles (Burka gudina kebele, Awasho kebele, and Arada kebele) were randomly selected from eight kebeles of the town, and systematic random sampling techniques was utilized to select households with children aged 6–23 months. Proportional sample to population size allocation was made for the three selected kebeles. House-to-house visits were conducted to reach the target number of 609. When we have more than one child in the same house between the ages of 6 and 23 months, we selected the younger one for the study. After selecting the eligible child, the mother of the child or the primary caregiver were interviewed.

Variables of the study

The outcome variable of this study was inappropriate complementary feeding practice. The exposure variables were mother or caregiver age, marital status, occupation, educational status, family size, monthly income of the family, exposure to media, decision making role on household income, food restriction, age of the child, place of delivery assistance, birth order, and antenatal visit.

Data collection procedures

Data were collected using a pre-tested structured interviewer-administered questionnaire. The questionnaire was developed and adopted from the validated EDHS and WHO questionnaire for IYCF [13, 15]. The questionnaire was initially prepared in English and translated to Amharic and back translated to English by proficient speakers of both languages. The questionnaire had different sections that address socio-demographic and economic, child feeding practice, and health services characteristics. Mothers or primary caregivers with children aged 6 to 23 months were interviewed face-to-face. Four BSc degree holder nurses were recruited and trained for two days on data collection techniques and ethics. The data collection was made using 24 h recall dietary assessment method.

Operational definition

Timely introduction of complementary feeding

Percentage of infants 6–8 months of age who consumed solid, semi-solid or soft foods during the previous day [15].

Minimum dietary diversity

Percentage of children 6–23 months of age who consumed foods and beverages from at least five out of eight defined food groups during the previous day. The eight food groups used to calculate minimum dietary diversity were breast milk, grains, roots and tubers, legumes, nuts and seeds, dairy products, flesh foods, eggs, vitamin A-rich fruits and vegetables, and other fruits and vegetables [15].

Minimum meal frequency

Percentage of children 6–23 months of age who consumed solid, semi-solid or soft foods (but also including milk feeds for non-breastfed children) the minimum number of times or more during the previous day. Minimum is defined as two times for breastfed infants 6–8 months; three times for breastfed children 9–23 months; and four times for non-breast children 6–23 months [15].

Inappropriate complementary feeding practice

Assessed by using the three key indicators recommended by WHO [15], which include timely introduction of complementary feeding, minimum dietary diversity, and minimum meal frequency. If the child did not fulfill any of the three criteria, we classified the child as having inappropriate complementary feeding practice.

Data processing and analysis

Data was checked, coded and entered to Epi data version 7.2 and exported to SPSS version 20 for analysis. Descriptive statistics like frequencies and proportions were used to describe the data and presented using text and tables. Binary logistic regression analysis was used to identify the association between the outcome and exposure variables. The fitness of the model was checked using Hosmer-Lemeshow goodness-of-fit test and the p value was 0.279. Initially, bivariate analysis was carried out to identify candidate variables for multivariable analysis. Then, those exposure variables with P < 0.25 were entered into multivariable logistic regression to assess the degree of association between outcome and exposure variables. Adjusted Odds Ratio (AOR) with 95% confidence intervals (CI) was used to determine the level of association.

Results

Socio demographic and economic characteristics of study subjects

The response rate of this study was 96.4%. More than half of children (54.8%) were females and the median age of the children was 10.0 months. The majority (89.8%) of caregivers were married and 145 (23.8%) did not attend formal education. One hundred fifty nine (26.1%) care givers were housemakers. In terms of decision making role on the expenditure of the household, 221(36.3%) make decisions jointly (mothers and fathers of the children). More than half (61.4%) of caregivers listen to mass media (Table 1).

Table 1 Socio-demographic characteristics of the study participants in Shashemene, Southern Ethiopia 2021

Variables (n = 609)	Category	Frequency	Percent	
Sex of the child	Boy	275	45.2	
	Girl	334	54.8	
Child’s age in months	6–8	228	37.4	
	9–11	164	26.9	
	12–23	217	35.6	
Caregivers age in years	< 25	235	38.6	
	25–34	235	38.6	
	>=35	139	22.8	
Caregivers educational status	No formal education	145	23.8	
	Primary (1st -8th )	140	23.0	
	Secondary (9th -12th)	157	25.8	
	College and above	167	27.4	
Marital status of caregiver	Currently married	547	89.8	
	Currently not married	62	10.2	
Occupation of the caregiver	Homemaker	159	26.1	
	Government employee	162	26.6	
	NGO employee	84	13.8	
	Private business	172	28.2	
	Daily laborer	32	5.3	
Household family size	< 4	125	20.5	
	4–6	272	44.7	
	> 6	212	34.8	
Decision making on household expenditure	Husband	191	31.4	
Wife	197	32.3	
	Jointly	221	36.3	
Caregiver listen’s to mass media	Yes	374	61.4	
No	235	38.6	

Maternal obstetric and child feeding related characteristics

In this study, more than three fourth of the children (82.1%) were delivered at health facility. Two hundred ninety five (48.4%) of the children in the study were first or second child in their family’s birth order. Nearly half (48.9%) of the children had a birth interval of less than 24 months with their immediate elders. About half of the caregivers (50.08%) had no ANC follow-up for the index child. The majority (84.1%) of the caregivers did not receive information about complementary feeding during their ANC visits to the health centers. The majority (95.4%) of the children have ever breastfed. More than half (54.5%) of the children started breastfeeding immediately after birth and the majority (80.6%) of children are currently breastfeeding (Table 2).

Table 2 Maternal obstetric characteristics and feeding practice of the study participants in Shashemene, Southern Ethiopia 2021

Variables (n = 609)	Category	Frequency	Percent	
Place of delivery	Home	109	17.9	
	Health facility	500	82.1	
Birth order of the child in the family	First or second	295	48.4	
Third and above	314	51.6	
Interval between the index child & immediate elder	< 24 months	298	48.9	
24 + months	311	51.1	
Attended ANC visits	Yes	304	49.9	
	No	305	50.1	
Received information about complementary feeding in ANC	Yes	97	15.9	
No	512	84.1	
Ever breast feed your child	Yes	581	95.4	
	No	28	4.6	
First put your child to breast	Within one hour of birth	332	54.5	
	After one hour & before one day	208	34.2	
	After one day	41	6.7	
Child is currently breastfeeding	Yes	491	80.6	
No	118	19.4	

Prevalence of complementary feeding practice

The overall prevalence of ICFP of children’s aged 6–23 months in this study was 337(55.3%). The timely initiation of complementary feeding, minimum dietary diversity and minimum meal frequency were 46.3%, 74.5%, and 73.6% respectively (Table 3).

Table 3 Complementary feeding practice of the study participants in Shashemene, Southern Ethiopia 2021

Variable	Category	Frequency	Percent	
Timely introduction of complementary feeding	Yes	282	46.3	
No	327	53.7	
Minimum dietary diversity	Yes	454	74.5	
No	155	25.5	
Minimum meal frequency	Yes	448	73.6	
No	161	26.4	
Currently breastfeeding	Yes	491	80.6	
	No	118	19.4	
Inappropriate complementary feeding	Yes	337	55.3	
No	272	44.7	

Factors associated with inappropriate complementary feeding practices

Caregivers whose children were aged 9–11 months were 70% less likely to practice ICFP [AOR = 0.30, 95% CI: 0.19, 0.45]. On the other hand, caregivers under the age of 25 years and 25–34 years were about two times more likely to practice ICFP compared to those mothers aged 35 or older [AOR = 2.07, 95% CI: 1.30, 3.31] and [AOR = 1.82, 95% CI: 1.14, 2.91] respectively. Caregivers who have a regular job outside home were nearly three times more likely to practice ICFP compared to their counterparts [AOR = 2.73, 95% CI: 1.84, 4.05]. Caregivers whose households expenditure was decided solely by husbands were about two times more likely to practice ICFP compared to households whose expenditure was decided jointly [AOR = 2.41, 95% CI: 1.54–3.77] (Table 4).

Table 4 Factors associated with inappropriate complementary feeding practice of the study participants in Shashemene, Southern Ethiopia 2021

Variable (n = 609)	ICFP	COR (95% CI)	AOR (95% CI)	
No (%)	Yes (%)	
Age of the children	
6–8 months	136(59.6%)	92(40.4%)	0.78[0.53–1.15]	0.78[0.53–1.15]	
9–11 months	59(36.0%)	105(64.0%)	0.30[0.19–0.45]	0.30[0.19–0.45]*	
12–23 months	142(65.4%)	75(34.6%)	Ref	Ref	
Maternal age	
<= 24 years	142(60.4%)	93(37.2%)	1.64[1.08–2.50]	2.07[1.30–3.31]*	
25–34 years	128(54.5%)	107(45.5%)	1.29[0.84–1.96]	1.82[1.14–2.91] *	
>= 35	67(48.2%)	72(51.8%)	Ref	Ref	
Maternal occupation	
Full time home	66(41.5%)	93(58.5%)	Ref	Ref	
Have occupation	271(60.2%)	179(39.8%)	2.13[1.48–3.08]	2.73[1.84–4.05]*	
Maternal education	
No formal education	72(49.7%)	73(50.3%)	0.61[0.39–0.96]	0.53[0.32–1.89]	
Primary (1–8)	77(55.0%)	63(45.0%)	0.76[0.48–1.20]	0.74[0.44–1.24]	
Secondary (9–12)	85(54.1%)	72(54.9%)	0.73[0.47–1.14]	0.70[0.43–1.13]	
College & above	103(61.7%)	64(38.3%)	Ref	Ref	
Attended ANC follow-up	
Yes	161(53.0%)	143(47.0%)	Ref	Ref	
No	176(57.7%)	129(42.3%)	1.21[0.88–1.67]	1.22[0.86–1.74]	
Decision making on household expenditure	
Jointly	118(53.4%)	103(46.6%)	Ref	Ref	
Wife	94(47.7%)	103(52.3%)	0.80[0.54–1.17]	0.87[0.57–1.32]	
Husband	125(65.4%)	66(34.6%)	1.65[1.11–2.46]	2.41[1.54–3.77]*	
Listening to mass media	
Yes	200(53.5%)	174(46.5%)	Ref	Ref	
No	137(58.3%)	98(41.7%)	1.22[0.88–1.69]	1.27[0.87–1.84]	
*Statistical significance at p < 0.05

Discussion

This study has attempted to quantify inappropriate complementary feeding practices and identify the factors associated with it among children aged 6–23 months. The results of this study revealed that the prevalence of ICFP was 55.3%. Age of the child, maternal age, maternal occupation, and decision making on household income were the variables identified to be significantly associated with inappropriate complementary feeding.

This study has reported 55.3% overall prevalence of ICFP among children aged 6–23 months. The prevalence of timely introduction of complementary feeding, minimum dietary diversity, and minimum meal frequency were found to be 46.3%, 74.5%, and 73.6%, respectively. This prevalence of ICFP is lower compared to a systematic review conducted in Ethiopia where the pooled prevalence of ICFP was 78.2% [16]. A study from Western Ethiopia reported a prevalence level of 90.1% and another study from Southern Ethiopia reported 79% prevalence of ICFP [17, 18]. A comparable prevalence level (46.5%) was reported in Eastern Ethiopia [19]. When compared to studies done in Nepal (70% and 82%) and Sri Lanka (84% and 88%), the finding of the current study shows lower rates of timely introduction of complementary foods and minimum meal frequency [8, 18]. A lower prevalence of minimum diet diversity was reported in Sudan (24%), Tanzania (38.2%) and Pakistan (22%) compared to the current study [20–22]. A higher minimum meal frequency (63%) was reported in Pakistan [22]. These differences in the prevalence level could be attributed to the difference in the socio-demographic status of the study areas. The current study was conducted in an urban setting, whereas the previous studies conducted in different regions of Ethiopia included participants from rural parts.

It was reported in the current study that mothers who have children aged 9–11 months were 70% less likely to practice ICFP compared to their older counterparts. This finding is consistent with other studies conducted in Tanzania, West Africa, Bangladesh and Pakistan, where mothers who have children 6–11 months were more likely to practice ICFP [20, 23–26].

This research revealed that mothers under the age of 25 and those aged 25–34 years were about two times more likely to practice ICFP compared to mothers aged 35 years and older. This finding is consistent with a study done in the Middle East and North Africa region [21]. This might be because of the fact that exposure to child care practices becomes better through experience as maternal age increases [21].

According to the findings of the current study, maternal occupation was found to be an independent predictor of ICFP. Working mothers were about 2.7 times more likely to practice ICFP than mothers who stayed at home [27]. This could be because employed women spend most of their time outside of home and give less time and attention to their children. On the contrary, other studies conducted in Ethiopia and West Africa reported that non-working mothers were more likely to practice ICFP [26]. These studies have justified that women who does not have their own income depend on their husband to purchase food for the children. However, in the current study about 68.6% of the women involve in the decision making of the household expenditure.

Mothers whose household expenses were decided by husbands were 2.4 times more likely to practice ICFP than households whose income expenses were decided jointly. This finding is consistent with findings reported in South Ethiopia [28]. This might be because husbands are less likely to participate in complementary feeding practice of their children in Ethiopian context [29]. The responsibility of child feeding is on the shoulder of mothers and if they can access household resources, they can contribute to child feeding [30].

Studies in different parts of the world have revealed that maternal educational status, attending ANC and Postnatal care follow-up, and exposed to mass media are predictors of ICFP [23, 26, 27, 31]. However, these variables were found to have no association with ICFP in the current study. In the current study, the proportion of women who gave birth at home, did not attend ANC follow-up and did not receive information or counselling about complementary feeding during ANC were significant. Studies have reported that women who gave birth at home have a higher odds of practicing inappropriate child feeding [32, 33]. Receiving information or counselling about complementary feeding was also a predictor in other studies [32, 34].

Limitations of the study

The study has interviewed the mothers about their past experience and may lead to possible recall bias. In addition, the study is a cross-sectional and thus it might not be possible to determine cause-effect relationship.

Conclusions

Appropriate behavioral change communication to family and community decision-makers are essential for improving complementary feeding practices with special emphasis given to food demonstration activities, timely introduction of complementary feedings, and food frequency to boost the IYCF program. Specifically, mothers should be made aware of their childrens’ (6–23 months old) food consumption and engaging husbands in IYCF is essential. All mothers who attend a health facility should get nutritional counseling on child feeding practice.

Acknowledgements

We would like to thank the School of Public Health, WSU institution review board for providing ethical approval letter for this research process. We would also like to acknowledge Shashemene Town Health office and local authorities for giving permission and for their cooperation to conduct this study. We are also grateful to the study participants for their voluntarily participation in the study, and the data collectors and supervisors for their effort.

Author contributions

EGA conceived the study and involved in designing the protocol, coordinating data collection, analyzing the data, and interpreting the findings. TD, DN, ADK and SKD contributed to the design, analysis, and interpretation of the findings, and reviewed progressive drafts of the manuscript and proofread the manuscript. All authors read and approved the final version of the manuscript.

Funding

No funding has been received to conduct this study.

Data availability

The datasets analyzed for this study are available with the corresponding author which can be accessed on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from the institutional review board at the College of Health Science and Medicine, Wolaita Sodo University in Ethiopia with an ethical approval reference number CRCSO77/0113. Permission letter together with the ethical clearance letter was presented to Shashemene town health office and permission was obtained sequentially from this office and its lower administrative structures. Informed written consent was obtained from each participants. Caregivers with a high perceived risk of poor feeding practices were counseled about appropriate feeding practices after the completion of the interview.

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

ANC Ante-Natal Care

AOR Adjusted Odds Ratio

CI Confidence Interval

COR Crude Odds Ratio

EDHS Ethiopian Demographic and Health Survey

ICFP Inappropriate Complementary Feeding practice

IYCF Infant and Young Child Feeding

NGO Non-Governmental Organization

SPSS Statistical Software for Social Science

WHO World Health Organization

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Mihretie Y. Assessment of complementary feeding practice of infants and young children aged 6–23 months in Gode Town. Somali Regional State of Ethiopia; 2017.
2. WHO, UNICEF Global strategy for infant and young child feeding 2003 Geneve WHO
WHO, UNICEF. Global strategy for infant and young child feeding. Geneve: WHO; 2003.
3. Kassa T Meshesha B Haji Y Ebrahim J Appropriate complementary feeding practices and associated factors among mothers of children age 6–23 months in Southern Ethiopia, 2015 BMC Pediatr 2016 16 1 1 10 10.1186/s12887-016-0675-x 26728595
Kassa T, Meshesha B, Haji Y, Ebrahim J. Appropriate complementary feeding practices and associated factors among mothers of children age 6–23 months in Southern Ethiopia, 2015. BMC Pediatr. 2016;16(1):1–10.26728595 10.1186/s12887-016-0675-x
4. Darnton-Hill I. Interventions for improving complementary feeding practices. WHO; 2017.
5. Masuke R Msuya SE Mahande JM Diarz EJ Stray-Pedersen B Jahanpour O Effect of inappropriate complementary feeding practices on the nutritional status of children aged 6–24 months in urban Moshi, Northern Tanzania: Cohort study PLoS ONE 2021 16 5 e0250562 10.1371/journal.pone.0250562 33983950
Masuke R, Msuya SE, Mahande JM, Diarz EJ, Stray-Pedersen B, Jahanpour O, et al. Effect of inappropriate complementary feeding practices on the nutritional status of children aged 6–24 months in urban Moshi, Northern Tanzania: Cohort study. PLoS ONE. 2021;16(5):e0250562.33983950 10.1371/journal.pone.0250562
6. Black RE Victora CG Walker SP Bhutta ZA Christian P de Onis M Maternal and child undernutrition and overweight in low-income and middle-income countries Lancet 2013 382 9890 427 51 10.1016/S0140-6736(13)60937-X 23746772
Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51.23746772 10.1016/S0140-6736(13)60937-X
7. UNICEFBank WHO Levels and trends in child malnutrition: key findings of the 2020 Edition of the Joint child Malnutrition estimates 2020 Geneva WHO
UNICEF, Bank WHO. W. Levels and trends in child malnutrition: key findings of the 2020 Edition of the Joint child Malnutrition estimates. Geneva: WHO; 2020.
8. Jones G Steketee RW Black RE Bhutta ZA Morris SS How many child deaths can we prevent this year? Lancet 2003 362 9377 65 71 10.1016/S0140-6736(03)13811-1 12853204
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet. 2003;362(9377):65–71.12853204 10.1016/S0140-6736(03)13811-1
9. Wormer JR, Shankar A, Van Hensbroek MB, Hindori-Mohangoo AD. Poor adherence to the WHO guidelines on feeding practices increases the risk for respiratory infections in Surinamese Preschool Children. 2021;18(20).
10. Ahmed KY Page A Arora A Ogbo FA Associations between infant and young child feeding practices and acute respiratory infection and diarrhoea in Ethiopia: a propensity score matching approach PLoS ONE 2020 15 4 e0230978 10.1371/journal.pone.0230978 32236145
Ahmed KY, Page A, Arora A, Ogbo FA. Associations between infant and young child feeding practices and acute respiratory infection and diarrhoea in Ethiopia: a propensity score matching approach. PLoS ONE. 2020;15(4):e0230978.32236145 10.1371/journal.pone.0230978
11. WHO, Comlementary feeding Geneve WHO. 2023 [10/13/2023]. https://www.who.int/health-topics/complementary-feeding#tab=tab_1
12. Institute EPH Ethiopia Mini Demographic and Health Survey 2019: key indicators 2019 Maryland, USA: EPHI ICF Rockville
Institute EPH. ICF. Ethiopia Mini Demographic and Health Survey 2019: key indicators. Maryland, USA: EPHI ICF;: Rockville; 2019.
13. Ethiopia C, ICF. Ethiopia Demographic and Health Survey 2016 Key indicators Report 2016 Maryland, USA: CSA ICF Addis Ababa, Ethiopia Rockville
Ethiopia. C, ICF. Ethiopia Demographic and Health Survey 2016 Key indicators Report. Maryland, USA: CSA ICF;: Addis Ababa, Ethiopia Rockville; 2016.
14. Beyene M Worku AG Wassie MM Dietary diversity, meal frequency and associated factors among infant and young children in Northwest Ethiopia: a cross- sectional study BMC Public Health 2015 15 1007 10.1186/s12889-015-2333-x 26433689
Beyene M, Worku AG, Wassie MM. Dietary diversity, meal frequency and associated factors among infant and young children in Northwest Ethiopia: a cross- sectional study. BMC Public Health. 2015;15:1007.26433689 10.1186/s12889-015-2333-x
15. WHO, UNICEF Indicators for assessing infant and young child feeding practices: definitions and measurement methods 2021 Geneve WHO
WHO, UNICEF. Indicators for assessing infant and young child feeding practices: definitions and measurement methods. Geneve: WHO; 2021.
16. Dagne AH Zewude SB Semahegn AM Appropriate complementary feeding practice and its Associated factors among mothers who have children aged between 6 and 24 months in Ethiopia: systematic review and Meta-analysis J Nutr Metab 2022 2022 1548390 10.1155/2022/1548390 36245817
Dagne AH, Zewude SB, Semahegn AM. Appropriate complementary feeding practice and its Associated factors among mothers who have children aged between 6 and 24 months in Ethiopia: systematic review and Meta-analysis. J Nutr Metab. 2022;2022:1548390.36245817 10.1155/2022/1548390
17. Fanta M, Cherie HA. Magnitude and determinants of appropriate complementary feeding practice among mothers of children age 6–23 months in Western Ethiopia. 2020;15(12):e0244277.
18. Himbego DG Hanfore LK Dake SK Appropriate complementary feeding practice among mothers of 6–23 months old children in Kedida Gamela district, south Ethiopia: a community based cross-sectional study Int J Nutr Metabolism 2019 11 3 19 26 10.5897/IJNAM2019.0252
Himbego DG, Hanfore LK, Dake SK. Appropriate complementary feeding practice among mothers of 6–23 months old children in Kedida Gamela district, south Ethiopia: a community based cross-sectional study. Int J Nutr Metabolism. 2019;11(3):19–26.10.5897/IJNAM2019.0252
19. Ebroshe M Oljira L Mengiste B Adem HA Alemu A Fekadu G Complementary feeding practices and associated factors among children aged 6–23 months in rural Haramaya district, Eastern Ethiopia: a community-based cross-sectional study Nutr Health 2023 29 3 523 30 10.1177/02601060221082373 35234106
Ebroshe M, Oljira L, Mengiste B, Adem HA, Alemu A, Fekadu G. Complementary feeding practices and associated factors among children aged 6–23 months in rural Haramaya district, Eastern Ethiopia: a community-based cross-sectional study. Nutr Health. 2023;29(3):523–30.35234106 10.1177/02601060221082373
20. Victor R Baines SK Agho KE Dibley MJ Factors associated with inappropriate complementary feeding practices among children aged 6–23 months in Tanzania Matern Child Nutr 2014 10 4 545 61 10.1111/j.1740-8709.2012.00435.x 22925557
Victor R, Baines SK, Agho KE, Dibley MJ. Factors associated with inappropriate complementary feeding practices among children aged 6–23 months in Tanzania. Matern Child Nutr. 2014;10(4):545–61.22925557 10.1111/j.1740-8709.2012.00435.x
21. Shaker-Berbari L, Qahoush Tyler V, Akik C. Predictors of complementary feeding practices among children aged 6–23 months in five countries in the Middle East and North Africa region. 2021;17(4):e13223.
22. Na M, Aguayo VM, Arimond M, Stewart CP. Risk factors of poor complementary feeding practices in Pakistani children aged 6–23 months: a multilevel analysis of the demographic and Health Survey 2012–2013. 2017;13 Suppl 2(Suppl 2).
23. Na M, Aguayo VM, Arimond M, Stewart CP. Risk factors of poor complementary feeding practices in Pakistani children aged 6–23 months: a multilevel analysis of the demographic and Health Survey 2012–2013. Matern Child Nutr. 2017;13 Suppl 2(Suppl 2).
24. Chowdhury MR Rahman MS Khan MM Levels and determinants of complementary feeding based on meal frequency among children of 6 to 23 months in Bangladesh BMC Public Health 2016 16 1 944 10.1186/s12889-016-3607-7 27604631
Chowdhury MR, Rahman MS, Khan MM. Levels and determinants of complementary feeding based on meal frequency among children of 6 to 23 months in Bangladesh. BMC Public Health. 2016;16(1):944.27604631 10.1186/s12889-016-3607-7
25. Issaka AI Agho KE Page AN Burns PL Stevens GJ Dibley MJ Determinants of suboptimal complementary feeding practices among children aged 6–23 months in four anglophone west African countries Matern Child Nutr 2015 11 1Suppl 1 14 30 10.1111/mcn.12194 26364789
Issaka AI, Agho KE, Page AN, Burns PL, Stevens GJ, Dibley MJ. Determinants of suboptimal complementary feeding practices among children aged 6–23 months in four anglophone west African countries. Matern Child Nutr. 2015;11(1Suppl 1):14–30.26364789 10.1111/mcn.12194
26. Issaka AI Agho KE Page AN Burns PL Stevens GJ Dibley MJ Determinants of suboptimal complementary feeding practices among children aged 6–23 months in seven francophone west African countries Matern Child Nutr 2015 11 1Suppl 1 31 52 10.1111/mcn.12193 26364790
Issaka AI, Agho KE, Page AN, Burns PL, Stevens GJ, Dibley MJ. Determinants of suboptimal complementary feeding practices among children aged 6–23 months in seven francophone west African countries. Matern Child Nutr. 2015;11(1Suppl 1):31–52.26364790 10.1111/mcn.12193
27. Joshi N Agho KE Dibley MJ Senarath U Tiwari K Determinants of inappropriate complementary feeding practices in young children in Nepal: secondary data analysis of demographic and Health Survey 2006 Matern Child Nutr 2012 8 Suppl 1 45 59 10.1111/j.1740-8709.2011.00384.x 22168518
Joshi N, Agho KE, Dibley MJ, Senarath U, Tiwari K. Determinants of inappropriate complementary feeding practices in young children in Nepal: secondary data analysis of demographic and Health Survey 2006. Matern Child Nutr. 2012;8(Suppl 1):45–59.22168518 10.1111/j.1740-8709.2011.00384.x
28. Berhanu Z Alemu T Argaw D Predictors of inappropriate complementary feeding practice among children aged 6 to 23 months in Wonago District, South Ethiopia, 2017; case control study BMC Pediatr 2019 19 1 146 10.1186/s12887-019-1523-6 31077158
Berhanu Z, Alemu T, Argaw D. Predictors of inappropriate complementary feeding practice among children aged 6 to 23 months in Wonago District, South Ethiopia, 2017; case control study. BMC Pediatr. 2019;19(1):146.31077158 10.1186/s12887-019-1523-6
29. Wolkanto AA Gemebo TD Dake SK Hailemariam TG Fathers’ involvement in complementary feeding of children in Damot Woyde District, South Ethiopia: a community-based cross-sectional study BMC Nutr 2023 9 1 8 10.1186/s40795-023-00670-8 36627682
Wolkanto AA, Gemebo TD, Dake SK, Hailemariam TG. Fathers’ involvement in complementary feeding of children in Damot Woyde District, South Ethiopia: a community-based cross-sectional study. BMC Nutr. 2023;9(1):8.36627682 10.1186/s40795-023-00670-8
30. Development AE, Office ATEC. Initial Insight Mining and Pretest Research for Alive & Thrive Ethiopia. 2011.
31. Epheson B Birhanu Z Tamiru D Feyissa GT Complementary feeding practices and associated factors in Damot Weydie District, Welayta Zone, South Ethiopia BMC Public Health 2018 18 1 419 10.1186/s12889-018-5245-8 29587689
Epheson B, Birhanu Z, Tamiru D, Feyissa GT. Complementary feeding practices and associated factors in Damot Weydie District, Welayta Zone, South Ethiopia. BMC Public Health. 2018;18(1):419.29587689 10.1186/s12889-018-5245-8
32. Tadesse M Ali Dawed Y Fentaw Z Endawike A Adamu K Determinants of inappropriate complementary feeding among children 6–23 months of age in Dessie City Northeast Ethiopia: a case-control study BMC Nutr 2023 9 1 124 10.1186/s40795-023-00779-w 37924096
Tadesse M, Ali Dawed Y, Fentaw Z, Endawike A, Adamu K. Determinants of inappropriate complementary feeding among children 6–23 months of age in Dessie City Northeast Ethiopia: a case-control study. BMC Nutr. 2023;9(1):124.37924096 10.1186/s40795-023-00779-w
33. Sisay W Edris M Tariku A Determinants of timely initiation of complementary feeding among mothers with children aged 6–23 months in Lalibela District, Northeast Ethiopia, 2015 BMC Public Health 2016 16 1 884 10.1186/s12889-016-3566-z 27562072
Sisay W, Edris M, Tariku A. Determinants of timely initiation of complementary feeding among mothers with children aged 6–23 months in Lalibela District, Northeast Ethiopia, 2015. BMC Public Health. 2016;16(1):884.27562072 10.1186/s12889-016-3566-z
34. Biks GA Tariku A Wassie MM Derso T Mother’s infant and young child feeding (IYCF) knowledge improved timely initiation of complementary feeding of children aged 6–24 months in the rural population of northwest Ethiopia BMC Res Notes 2018 11 1 593 10.1186/s13104-018-3703-0 30115114
Biks GA, Tariku A, Wassie MM, Derso T. Mother’s infant and young child feeding (IYCF) knowledge improved timely initiation of complementary feeding of children aged 6–24 months in the rural population of northwest Ethiopia. BMC Res Notes. 2018;11(1):593.30115114 10.1186/s13104-018-3703-0
