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Feeding practices for infants and young children during andafter common illness. Evidence from South Asia

Kajali Paintal and Víctor M. AguayoRegional Office for South Asia, United Nations Children’s Fund (UNICEF), Kathmandu, Nepal

Abstract

Global evidence shows that children’s growth deteriorates rapidly during/after illness if foods and feeding practicesdo not meet the additional nutrient requirements associated with illness/convalescence. To inform policies andprogrammes, we conducted a review of the literature published from 1990 to 2014 to document how children0–23months old are fed during/after common childhood illnesses. The review indicates that infant and young childfeeding (IYCF) during common childhood illnesses is far from optimal. When sick, most children continue to bebreastfed, but few are breastfedmore frequently, as recommended. Restriction/withdrawal of complementary foodsduring illness is frequent because of children’s anorexia (perceived/real), poor awareness of caregivers’ about thefeeding needs of sick children, traditional beliefs/behaviours and/or suboptimal counselling and support by healthworkers. As a result, many children are fed lower quantities of complementary foods and/or are fed less frequentlywhen they are sick. Mothers/caregivers often turn to family/community elders and traditional/non-qualified practi-tioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours guide the use of‘special’ feeding practices, foods and diets for sick children. A significant proportion of mothers/caregivers turn tothe primary health care system for support but receive little or no advice. Building the knowledge, skills and capacityof community health workers and primary health care practitioners to providemothers/caregivers with accurate andtimely information, counselling and support on IYCF during and after common childhood illnesses, combined withlarge-scale communication programmes to address traditional beliefs and norms that may be harmful, is an urgentpriority to reduce the high burden of child stunting in South Asia.

Keywords: child feeding, common childhood illnesses, diarrhoea, pneumonia, South Asia.

Correspondence: Dr Kajali Paintal, UNICEF Regional Office for South Asia, PO Box 5815, Lekhnath Marg, Kathmandu, Nepal.E-mail: [email protected]

Introduction

About a quarter (26%) of the world’s children underfive live in South Asia. Thirty-eight per cent of themhave stunted growth (UNICEF 2015). Stunting, orlinear growth retardation during early childhood, is anoutcome of biological and/or psychosocial deprivation(Stewart et al. 2013). The short-term and long-termconsequences of stunting include impaired survival,physical growth and cognitive development in pre-school age children; poor school readiness, schoolenrolment and learning outcomes in school-age chil-dren; increased risk of obstetric complications and

mortality in women; and reduced height, productivityand earnings in adults (Grantham-McGregor et al.2007; Walker et al. 2007; de Onis et al. 2013).

A significant proportion of stunting can happen pre-natally. However, evidence indicates that most stuntingin low-income and middle-income countries occursduring the first 24months of life as a result of subopti-mal breastfeeding and complementary feeding prac-tices, often in combination with recurrent infections(Stewart et al. 2013; Jones et al. 2014). Furthermore,children’s nutritional status can deteriorate rapidlyduring/after illness if the additional nutrient require-ments associated with illness/convalescence are not

© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons LtdMaternal & Child Nutrition (2016), 12 (Suppl. 1), pp. 39–71 39

DOI: 10.1111/mcn.12222

Review Article

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in anymedium, provided the original work is properly cited.

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met and nutrients are diverted from growth and devel-opment towards the immune response. Children’s poorappetite induced by illness can contribute to perpetuatethe vicious cycle of infection and stunting (Brown 2003;Ramachandran & Gopalan 2009; Gulati 2010;Neumann et al. 2012; Richard et al. 2014). Additionally,in low-income andmiddle-income countries, infant andyoung child feeding (IYCF) practices during and aftercommon childhood illnesses can be particularly poorowing to harmful traditional practices and the lowcoverage/quality of primary health care services(Bhutta & Salam 2012; de Onis et al. 2012; Stewartet al. 2013).

Recognizing the importance of optimal IYCFpractices for child survival, growth and development,the World Health Organization (WHO) launched in2003 the Global Strategy for Infant and Young ChildFeeding and issued in 2003 the Guiding Principlesfor Complementary Feeding of Breastfed and Non-Breastfed Children (WHO/UNICEF 2003; WHO2003a,b). These global frameworks highlight theimportance of optimal IYCF practices during andafter common childhood illnesses such as diarrhoeaand pneumonia and emphasize the need to increasefluid intake during illness while feeding is maintainedand increase food intake during convalescence. Inaddition, appropriate IYCF during and after illnessis part of the WHO-led Global Strategy for theIntegrated Management of Childhood Illnesses(WHO 2005). The definition and measurement of

the indicators for assessing IYCF practices – beyondthe scope of this paper – are comprehensively de-tailed elsewhere (WHO 2008, 2010).

In South Asia,1 breastfeeding is a quasi-universalpractice. An estimated 96% of children are breastfedat some point in their lives, and most (80%) continueto be breastfed at 2 years of age (Dibley et al. 2010;UNICEF 2015). However, data from householdsurveys across the region indicate that the majority ofSouthAsian children are not fed as per the internation-ally agreed upon recommendations: only a quarter(27%) of newborns start breastfeeding within 1 h ofbirth; less than half (48%) of infants 0–5months oldare exclusively breastfed; only about half (56%) ofinfants 6–8month olds are fed soft, semi-solid or solidfoods; and a mere 21% of children 6–23months oldare fed a diet that meets the minimum requirementsin terms of feeding frequency and diet diversity(Senarath et al. 2012; UNICEF 2015). In view of thissituation, researchers and practitioners have not hesi-tated to refer to IYCF in South Asia as a crisis (Memon2012). There is evidence that the incidence and severityof common childhood diseases are high in this region(Walker et al. 2013). However, less is known aboutIYCF practices during and after common childhoodillnesses in South Asia.

Key messages

• Information on infant and young child feeding (IYCF) behaviours and practices during common childhoodillnesses in South Asia is limited. Information of IYCF after illnesses is virtually inexistent. The evidenceavailable indicates that IYCF practices during common childhood illnesses are far from optimal.

• When sick, most children (up to 98%) continue to be breastfed although a significant proportion (up to 49%) isbreastfed less frequently than usual. Few sick children (<20%) are breastfed more frequently than usual, as isrecommended, to compensate for the additional fluid and nutrient requirements associated with illnesses.

• When sick, many children (up to 75%) see their complementary foods restricted in frequency, quantity and/orquality owing to children's anorexia (perceived or real), lack of awareness of caregivers' about the feedingneeds of sick children, traditional beliefs or suboptimal counselling and support by health workers.

• In general, health providers do not advise mothers to increase breastfeeding frequency while encouraging sickchildren to eat soft, varied and favourite foods during illness, as is recommended. Important policy, programmeand capacity gaps exist with respect to IYCF for children during and after common childhood illnesses in manySouth Asian countries.

1For the purpose of this paper, South Asia refers to the eightmember countries of the South Asia Association for RegionalCooperation, namelyAfghanistan, Bangladesh, Bhutan, India,Maldives, Nepal, Pakistan and Sri Lanka.

40 K. Paintal and V.M. Aguayo

© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd Maternal & Child Nutrition (2016), 12 (Suppl. 1), pp. 39–71

Thus, the objective of this paper is threefold: (1) doc-ument the current IYCF practices during and aftercommon childhood illnesses – particularly diarrhoea,fever and pneumonia – and their trends since 1990 inSouth Asia; (2) document caregiver’s behaviours andhealth providers’ practices with respect to IYCF duringand after common childhood illnesses in South Asia;and in light of the preceding objectives, (3) identify pri-orities in terms of policy formulation, programmedesign, research and advocacy to protect, promoteand support optimal IYCF practices during and aftercommon childhood illnesses in South Asia post 2015.

Methods

We reviewed data and information from two primarysources: Demographic Health Surveys (DHS) andpeer-reviewed publications. DHS collects informationon care-seeking and care-giving practices during diar-rhoea, fever and pneumonia using standardized sam-pling methodologies, interview tools and data analysesprocedures, with minor country-specific adaptations.We reviewed the national DHS surveys conducted inSouth Asia between 1990 and 2014 to document theprevalence of common childhood illnesses – diarrhoea,fever and pneumonia – in children 0–23months old, thefrequency and type of medical advice that caregiverssought, the type of treatment and/or advice thatchildren received and how children were fed duringcommon childhood illnesses. For countries with twodata points, trends in IYCF practices during and aftercommon childhood illness were estimated as well asthe average annual rate of improvement to quantifythe average improvement in a given indicator per yearbetween the base year and end year.

We also conducted a comprehensive review of thepeer-reviewed literature published between January1990 and December 2014. Peer-reviewed articleswere identified through an online PubMed searchusing the following search terms and searchfilters: (1) search terms: <feeding>, <sick>,<morbidity>, <pneumonia>, <diarrhea/diarrhoea>and <IMCI/IMNCI>, each term combinedwith <Afghanistan>, <Bangladesh>, <Bhutan>,<India>, <Maldives>, <Nepal>, <Pakistan>, <Sri

Lanka> and/or <Asia>; (2) search filters: age <child0–59months>; language: <English>; text availability:<abstract>; species :<human>; and search fields:<title/abstract>. Although children 0–23months oldare the focus of our analysis, we expanded our ‘childage’ search criteria to 0–59months to capture addi-tional publications that, while focusing on ‘childrenunder five’ or ‘preschool-age children’, also addressIYCF practices in the first 2 years of life.

The PubMed search identified 367 publicationswith one or more of the search terms in the titleand/or abstract. In-depth scrutiny of the titlesexcluded 158 publications as not relevant to ourreview and identified 209 as potentially relevant.In-depth scrutiny of the abstracts of these 209 publi-cations excluded 126 as not relevant to our reviewand identified 83 as likely relevant. Lastly, full-textscrutiny of these 83 publications excluded 54 as notrelevant to our review and identified 29 articles thatwere relevant to our review. In addition, we reviewedthe bibliographic references of these 29 papers toidentify any additional publication that could havebeen missed by our online search and found threeadditional publications that were relevant to ouranalysis. Hence, 32 publications were included inour analysis as they focused specifically on IYCFpractices during diarrhoea, fever and/or pneumoniain South Asian countries (Fig. 1).

In addition, we conducted interviews with 13 keyinformants. The purpose of the key informant inter-views was not to collect key informants’ views, opin-ions or recommendations but rather to help theauthors of the paper identify the existing nationalpolicies, guidelines and programmes related to IYCFduring and after common childhood illnesses in theeight countries included in the analysis. In the fivelarge countries (Afghanistan, Bangladesh, India,Nepal and Pakistan), we interviewed two UNICEFstaff by country, namely the Chief of Health and theChief of Nutrition, while in the three smallercountries (Bhutan, Maldives and Sri Lanka), weinterviewed one UNICEF staff per country, namelythe Chief of the Health and Nutrition programme.This made a total of 13 key informants who in turnconsulted with relevant national counterparts tocomplete the information-gathering process.

Infant feeding during and after illness in South Asia 41

© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd Maternal & Child Nutrition (2016), 12 (Suppl.1), pp. 39–71

Findings

Household survey evidence on infant and youngchild feeding and care practices during and afterillness

Six countries – Bangladesh, India, Maldives, Nepal,Pakistan and Sri Lanka – had at least one DHS sur-vey that included information on common childhoodillnesses and IYCF practices (Afghanistan’s 2010DHS did not include data collection on child morbid-ity, and no DHS survey was available for Bhutan).DHS survey data indicate that in the countriesincluded in the analysis, children 0–23months old

suffer from common childhood illnesses frequently.Up to 20–30% of the mothers/caregivers interviewedreported that their children had suffered fromdiarrhoea or pneumonia in the 2weeks prior to thesurvey. The prevalence of common childhood illnesses– diarrhoea, fever and pneumonia – was highest inPakistan. In all countries, the prevalence of fever washigher than the prevalence of diarrhoea orpneumonia. Similarly, in all countries, the prevalenceof common childhood illnesses was lowest during theexclusive breastfeeding period (0–5months) andhighest during the early complementary feedingperiod (6–11months) (Table 1).

Fig. 1. Flow diagram of literature review.



The proportion of caregivers who sought medicaladvice in the event of diarrhoea was highest in Indiaand Pakistan (>60%); the proportion of caregiverswho sought medical advice in the event of fever washighest in Maldives and Sri Lanka (>80%); lastly,the proportion of caregivers who sought medical ad-vice in the event of pneumonia was highest in Indiaand Pakistan (>65%). The lowest proportion of care-givers seeking medical advice for common childhoodillnesses was recorded in Bangladesh (30.1%, 31.4%and 41.4% for diarrhoea, fever and pneumonia,respectively (Table 2).

Data on the type of treatment/care provided tochildren 0–23months old who experienced diarrhoea,fever or pneumonia in the 2weeks preceding the surveyand for whom advice or treatment was sought from a

health facility or health provider were available forBangladesh, India, Nepal and Pakistan. The proportionof children who received oral rehydration solutions(ORS) or increased fluids was highest in Bangladesh(>75%) and lowest in India (<20%) (Table 3). Simi-larly, the proportion of children who received antibiotictherapy for the treatment of fever and pneumonia washighest in Bangladesh (>66%) and lowest in India(<15%) (Table 4).

In these four countries – Bangladesh, India, Nepaland Pakistan – DHS information on IYCF practicesduring/after common childhood illnesses focused onlyon feeding practices during diarrhoea (Table 5). Noinformation was available on IYCF practices whenchildren had fever or pneumonia or after episodes ofdiarrhoea, fever or pneumonia. The proportion of

Table 1. Number and percentage of children 0–23months old who experienced diarrhoea, fever or pneumonia in the 2 weeks preceding the survey(South Asia, Demographic and Health Surveys)

Prevalence of common childhood diseases

n Diarrhoea (%) Fever (%) Pneumonia (%)

Bangladesh, 20110–5 months 816 3.1 35.1 6.26–11months 864 8.4 49.2 7.412–23months 1 547 7.1 42.6 6.90–23months 3 227 6.4 42.5 6.9

India, 20060–5 months 5 127 10.6 11.6 6.26–11months 5 276 18.1 21.1 8.112–23months 10 419 13.8 19.1 7.10–23months 20 822 14.1 17.8 7.1

Maldives, 20090–5 months 406 2.5 21.8 —

6–11months 441 6.9 34.4 —

12–23months 822 6.7 33.7 —

0–23months 1 669 5.7 31.0 <1Nepal, 2011

0–5 months 531 12.9 17.1 3.96–11months 491 24.1 29.7 7.512–23months 1 000 23.9 24.2 7.90–23months 2 022 21.1 23.7 6.8

Pakistan, 20120–5 months 1 164 25.8 33.8 15.36–11months 1 024 35.3 49.8 21.212–23months 2 074 32.9 46.4 20.20–23months 4 262 31.5 43.8 19.1

Sri Lanka, 20070–5 months 634 1.5 9.5 2.26–11months 739 9.1 22.8 4.912–23months 1 438 4.7 21.5 5.00–23months 2 811 5.1 19.1 4.3



Table 2. Among children 0–23months old who experienced diarrhoea, fever or pneumonia in the 2 weeks preceding the survey, number and percentagefor whom advice/treatment was sought from a health facility or health provider (South Asia, Demographic and Health Surveys)

Bangladesh 2011 India 2006 Maldives 2009 Nepal 2011 Pakistan 2012 Sri Lanka 2007

N (%) N (%) N (%) N (%) N (%) N (%)

Diarrhoea0–5months 25 (43.6) 542 (57.1) — 68 (32.6) 300 (60.0) —

6–11months 73 (30.1) 956 (60.3) — 118 (41.6) 361 (60.8) —

12–23months 109 (27.0) 1434 (66.1) — 239 (40.2) 682 (68.0) —

0–23months 207 (30.1) 2932 (62.5) — 425 (39.4) 1343 (64.3) —

Fever0–5months 155 (36.0) 593 (71.0) 88 (79.9) 91 (34.2) 394 (66.7) 60 (62.5)6–11months 284 (32.8) 1113 (76.4) 152 (86.2) 146 (45.9) 51 (64.9) 169 (87.5)12–23months 466 (29.0) 1991 (71.4) 277 (84.5) 242 (46.2) 962 (66.0) 310 (85.5)0–23months 905 (31.4) 3697 (72.8) 517 (84.2) 479 (43.8) 1407 (66.2) 539 (83.6)

Pneumonia0–5months 51 (39.8) 319 (70.7) — — 178 (70.7) 14 (0.0)6–11months 64 (42.8) 427 (76.9) — — 217 (62.7) 37 (67.6)12–23months 106 (41.4) 743 (69.0) — — 420 (65.5) 71 (65.7)0–23months 221 (41.4) 1489 (71.6) — — 815 (65.9) 122 (58.7)

Table 3. Among children 0–23months old who experienced diarrhoea in the 2 weeks preceding the survey and for whom advice or treatment wassought from a health facility or health provider, percentage according to the type of treatment/care that they were provided during the diarrhoea episode(South Asia, Demographic and Health Surveys)

ORS RHF

ChildrengivenORS orRHF

Childrengivenincreasedfluids

Zn treatment

Znsyrup

Zntablet

Znsupplements

Zn+ORS

Bangladesh, 20110-5 months 46.1 0.0 46.1 1.7 13.9 7.2 — 8.86–11months 73.4 9.3 76.2 23.0 39.4 21.9 — 35.812–23months 75.7 7.1 77.7 25.5 32.0 23.2 — 39.70–23months 71.3 9.8 73.4 21.7 32.4 21.5 — 34.6

India, 20060–5months 13.7 15.6 15.6 2.6 — — 0.0 —

6–11months 21.3 15.9 31.8 7.9 — — 0.5 —

12–23months 34.6 23.6 48.0 11.1 — — 0.3 —

0–23months 26.4 20.8 36.7 8.5 — — 0.3 —

Nepal, 20110–5months 5.8 — 5.8 13.6 — — 1.8 0.06–11months 35.2 — 35.2 9.3 — — 5.7 4.612–23months 48.2 — 48.2 17.7 — — 6.3 6.20–23months 37.8 — 37.8 14.7 — — 5.4 4.8

Pakistan, 20120–5months 25.9 3.3 27.2 7.9 — — 0.6 —

6–11months 38.8 10.5 42.7 5.3 — — 0.3 —

12–23months 44.4 11.0 48.5 8.2 — — 2.7 —

0–23months 38.8 23.6 42.2 7.4 — — 1.6 —

ORS, oral rehydration solution; RHF, recommended home fluids.



mothers/caregivers who fed their children more/samefluids as usual was highest in Bangladesh (72.6%) andlowest in India (Table 5).

We were able to examine time trends in four coun-tries – Bangladesh, India, Nepal and Pakistan, wherethree DHS surveys were available for the period1990–2014. Bangladesh and Nepal made significantprogress in reducing the prevalence of diarrhoea, feverand pneumonia in children 0–23months old, mirroredby significant increases in care-seeking behaviour forthese common childhood illnesses. Improvements inIndia were low to nil, while surveys in Pakistanreported a significant deterioration (Table 6).

Table 7 summarizes the trends in feeding and carepractices for children 0–23 during diarrhoea episodes.Over the 1990–2014 period, the proportion of childrenwith diarrhoea who were given Oral RehydrationSolution (ORS) increased in Bangladesh, India andNepal, while there was no improvement in Pakistan.The proportion of children who were not given ORS/recommended home fluids/increased fluids declined inall countries. The highest average annual rate of

reduction was recorded in Bangladesh (0.41) and thelowest in India (0.11). Detailed information on trendsin IYCF during diarrhoea was available only for Nepal(2006–2011) and Pakistan (2007–2012). In both coun-tries, most mothers reported that the amount of liquidsoffered to their infants during the diarrhoea episodewas ‘same as usual’ in both base year and end year.Only about half the mothers in Nepal and one-thirdof mothers in Pakistan reported that the amount offood offered to their children was ‘same than usual’ –with no improvement between base year and end year.

Research evidence on caregivers’ behaviours andhealth providers’ practices on infant and young childfeeding during and after common childhoodillnesses

The bibliographic search identified 32 peer-reviewedpublications that met the inclusion criteria for thisreview. One study (3%) was from Nepal, eight studies(25%)were fromBangladesh, seven studies (22%)werefrom Pakistan and 15 studies (47%) were from India.

Table 4. Among children 0–23months old who experienced fever or pneumonia in the 2 weeks preceding the survey and for whom advice or treatmentwas sought from a health facility or health provider, percentage according to the type of treatment/care that they were provided during the fever/pneumoniaepisode (South Asia, Demographic and Health Surveys)

No. ofchildrenwith fever

Percentage of children withfever who receivedantimalarial drugs

Percentage of children withfever who receivedantibiotic drugs

No. ofchildren withpneumonia

% of children withpneumonia who receivedantibiotic drugs

Bangladesh, 20110–5 months; 286 1.8 54.3 51 69.16–11months 425 0.1 66.9 64 81.812–23months 659 0.9 70.7 106 78.00–23months 1 370 0.8 66.1 221 77.0

India, 20060–5 months 5 127 7.5 14.6 319 14.66–11months 5 276 7.2 14.9 427 11.912–23months 10 419 9.2 13.8 743 12.70–23months 20 822 8.3 14.3 1489 12.9

Nepal, 20110–5 months 91 1.8 29.4 — —

6–11months 146 0 34.4 — —

12–23months 242 1.5 38.1 — —

0–23months; 479 1.1 35.3 — —

Pakistan, 20120–5 months 394 2.4 32 178 41.46–11months 51 5.3 41.1 217 44.112–23months 962 4.0 40.0 420 43.50–23months 1 407 3.6 37.8 815 43.2



The majority of the studies (n = 31; 97%) reportedIYCF practices during common childhood illness,while only one study reported IYCF practices bothduring and after illness.

Thirty studies (94%) reported IYCF practices forchildren with diarrhoea, eight studies (25%) reportedIYCF practices for children with pneumonia and fivestudies (16%) reported IYCF practices for children withfever. Most studies (n=29; 91%) reported caregivers’IYCF behaviours when children were sick, while onlysix studies (19%) reported health providers’ IYCFcounselling to mothers of sick children. Twenty-eight

(88%) were observational studies. Only four (13%)studies – one in Bangladesh and three in India –

assessed the impact of one or more interventions toimprove IYCF practices during/after illness.

The findings of our review are organized aroundthe seven key focus areas (Table 8).

Breastfeeding during and after common childhood illnesses

Sixteen studies (50%) investigated whether childrencontinued to be breastfed while they were sick. All thestudies reported that most mothers (range 69.7–98.0%)

Table 5. Percentage distribution of children 0–23months old who had diarrhoea in the 2 weeks preceding the survey by amount of liquids and foodoffered during the diarrhoea episode compared with normal practice as reported by the mother/primary caregiver (South Asia, Demographic and HealthSurveys)

Bangladesh 2011 India 2006 Nepal 2011 Pakistan 2012

Liquids Solids Liquids Solids Liquids Solids Liquids Solids

(%) (%) (%) (%) (%) (%) (%) (%)

Children 0–5 monthsMore 1.7 0.0 2.6 1.7 13.6 0.0 7.9 0.9Same as usual 71.9 50.1 58.7 23.3 69.0 10.0 59.4 12.4Somewhat less 16.5 16.5 19.4 11.9 2.2 6.0 19.2 8.8Much less 5.3 5.3 7.0 6.9 0.0 3.4 6.7 6.9None 4.6 7.7 12.0 0.7 15.1 0.7 6.5 0.7Never gave food — — — 54.4 — 79.9 — 70.2Do not know or missing — — — 1.0 — 0.0 — 0.0

Children 6–11 monthsMore 23.0 14.9 7.9 1.9 9.3 5.5 5.3 1.4Same as usual 44.5 40.0 48.3 30.3 78.3 58.4 53.7 34.6Somewhat less 25.1 29.4 28.4 25.2 5.3 8.2 32.0 23.5Much less 7.0 9.3 9.7 7.4 0.0 1.9 6.5 6.4None 0.4 1.1 5.4 5.6 7.1 0.7 1.5 7.7Never gave food — 20.4 — 29.2 — 25.3 — 25.5Do not know or missing — — 0.4 0.3 0.0 0.0 0.8 0.8

Children 12–23monthsMore 25.5 12.5 11.1 1.7 17.7 10.1 8.2 2.7Same as usual 50.3 54.7 45.7 39.7 67.5 65.5 52.8 44.5Somewhat less 21.8 23.8 29.8 34.2 11.4 21.8 31.3 36.1Much less 2.4 4.4 10.6 13.6 1.1 2.1 7.5 9.9None — 4.5 2.4 4.0 2.4 0.5 0.3 3.9Never gave food — 0.2 — 6.0 — 0.0 — 3.0Do not know or missing — — 0.4 0.9 0.0 0.0 0.0 0.0

Children 0–23monthsMore 21.7 11.8 8.5 1.8 14.7 7.2 7.4 1.9Same as usual 50.9 49.0 49.0 33.6 70.7 54.6 54.5 34.7Somewhat less 22.3 24.9 27.4 27.1 8.2 15.5 28.8 26.6Much less 4.4 6.2 9.6 10.3 0.6 2.3 7.1 8.3None 0.7 3.4 5.2 5.1 5.7 1.0 2.0 5.6Never gave food — 1.1 — 0.4 — 0.4 — 0.3Do not know or missing 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0



continued to breastfeed their sick children irrespectiveof children’s age or the nature of their illness(Huffman & Combest 1990; Malik et al. 1991;Badruddin et al. 1991, 1997; Kaur et al. 1994; Singh1994; Bhuiya & Streatfield 1995; Piechulek et al.1999; Gupta & Gupta 2000; Mangala et al. 2000;Kaushal et al. 2005; Shah et al. 2011; Benakappa &Shivamurthy 2012; Dhadave et al. 2012; Dongre et al.2010; Giri & Phalke 2014). Three studies reported thatsome mothers (range 8.5–17.0%) breastfed their chil-dren more frequently when children were sick(Mangala et al. 2000; Dhadave et al. 2012; Giri &Phalke 2014); conversely, four studies reported thatsome mothers (range 4.3–49.3%) breastfed their sickchildren less frequently (Piechulek et al. 1999; Shahet al. 2011; Benakappa & Shivamurthy 2012; Giri &Phalke 2014); lastly, six studies reported that somemothers (range 1–9%) ceased to breastfeed whenchildren were sick (Kaur et al. 1994; Gupta & Gupta

2000; Mangala et al. 2000; Shah et al. 2011; Dhadaveet al. 2012; Giri & Phalke 2014). The three main rea-sons given by mothers for reducing or ceasingbreastfeeding while children were sick are: (1) the be-lief that infants could not digest breast milk when theywere sick (two studies; Piechulek et al. 1999; Shah et al.2011); (2) the perception that children wereanorexic/had no appetite and/or refused to be fed(two studies; Bhuiya & Streatfield 1995; Benakappa &Shivamurthy 2012); and/or (3) the belief that breastmilkhad become harmful to the child because ofmystical/evil forces and/or that the illness had beentransmitted by the mother to the child throughmother’smilk (three studies) (Bhuiya&Streatfield 1995; Kaushalet al. 2005; Benakappa & Shivamurthy 2012). Twostudies reported that a significant proportion ofmothers (range 35–61%) – particularly among thosewith young infants 0–11months old and/or childrenwith diarrhoea – switched back to predominant or

Table 6. Percentage of children 0–23months old who experienced diarrhoea, fever or pneumonia in the 2 weeks preceding the survey and for whomadvice/treatment was sought from a heath facility or health provider (Demographic Health Surveys, 1990–2013)

Bangladesh 1994 2004 2011 AARI*Children 0–23months old with diarrhoea (%) 13.2 10.1 6.4 �0.40Children with diarrhoea seeking medical advice (%) 20.6 18.8 30.1 +0.56Children 0–23months old with fever (%) — 46.4 42.5 �0.56Children with fever seeking medical advice (%) — 22.8 31.4 +1.23Children 0–23months old with pneumonia (%) 26.8 26.9 6.9 �1.17Children with pneumonia seeking medical advice (%) 29.3 25.4 41.4 +0.71

India 1992 1998 2006 AARI*Children 0–23months old with diarrhoea (%) 13.2 21.1 14.1 +0.06Children with diarrhoea seeking medical advice (%) 61.9 61.5 62.5 +0.04Children 0–23months old with fever (%) 22.8 30.3 17.8 �0.36Children with fever seeking medical advice (%) 67.7 — 72.8 +0.36Children 0–23months old with pneumonia (%) 7.4 20.2 7.1 �0.02Children with pneumonia seeking medical advice (%) 68.3 63.6 71.6 +0.24

Nepal 1996 2006 2011 AARI*Children 0–23months old with diarrhoea (%) 31.2 18.2 21.1 �0.67Children with diarrhoea seeking medical advice (%) 14.1 27.1 39.4 +1.69Children 0–23months old with fever (%) 41.2 21.5 23.7 �1.17Children with fever seeking medical advice (%) — 33.1 43.8 +2.14Children 0–23months old with pneumonia (%) 37.8 7.2 6.8 �2.07Children with pneumonia seeking medical advice (%) 18.3 42.8 — +2.45

Pakistan 1991 2007 2012 AARI*Children 0–23months old with diarrhoea (%) 19.2 31.6 31.5 +0.59Children with diarrhoea seeking medical advice (%) 51.0 57.4 64.3 �0.01Children 0–23months old with fever (%) 35.6 36.4 43.8 +0.39Children with fever seeking medical advice (%) 66.4 68.6 66.2 �0.01Children 0–23months old with pneumonia (%) 19.1 15.9 74.1 +0.00Children with pneumonia seeking medical advice (%) 68.4 74.1 65.9 �0.12

*Average annual rate of improvement (AARI) quantifies the average rate of change between base year and end year.



exclusive breastfeeding when children were sick(Ahmed et al. 1992; Shah et al. 2011).

Fluid intake during and after common childhood illnesses

Ten studies (31%) investigated whether children con-tinued to be given fluids when they experienced

common illnesses and/or whether fluid intake increasedor decreased when children were sick. Nine studies re-ported that most mothers (range 40–92%) continued toadminister fluids to their sick children (Kaur & Singh1994; Kaur et al. 1994; Piechulek et al. 1999; Gupta &Gupta 2000; Agha et al. 2007; Gupta et al. 2007; Dongreet al. 2010; Memon et al. 2010; Das et al. 2013). Two

Table 7. Percentage of children 0–23months old who experienced diarrhoea in the 2 weeks preceding the survey, by type of treatment/care they wereprovided and amount of liquids/food offered compared with normal practice (Demographic Health and Surveys, 1990–2013)

Bangladesh 1994 2004 2011 AARIChildren given ORS (%) 47.8 65.2 71.3 1.38Children given recommended home fluids (%) 14.3 17.9 7.0 �0.43Children given increased fluids (%) 48.8 48.6 21.7 �1.59Children not given ORS/recommended home fluids /increased fluids (%) 31.5 16.9 24.5 �0.41

India 1992 1996 2006Children given ORS (%) 17.8 25.5 26.4 0.61Children given recommended home fluids (%) 18.1 12.8 17.4 �0.05Children given increased fluids (%) 13.8 20.7 8.5 �0.38Children not given ORS/ recommended home fluids /increased fluids (%) 61.4 54.3 59.8 �0.11

Nepal 1996 2006 2011Children given ORS (%) 23.8 25.5 37.8 0.93Children given recommended home fluids (%) 4.2 — — —

Children given increased fluids (%) 33.1 20.1 14.7 �1.23Children not given ORS/recommended home fluids/increased fluids (%) 53.8 62.6 51.6 �0.15

Feeding practices: amount of liquids offered to children (%)More 20.1 14.7 �1.08Same as usual 63.4 70.7 1.46Less than usual 13.4 8.8 �0.92None 3.1 5.7 0.52

Feeding practices: amount of food offered to children (%)More 4.7 7.2 0.50Same as usual 53.3 54.6 0.26Less than usual 25.1 17.8 �1.46None 2.6 1.0 �0.32Never gave food 0.2 0.4 0.04

Pakistan 1991 2007 2012Children given ORS (%) 38.8 40.3 38.8 0.0Children given recommended home fluids (%) 14.7 15.8 9.1 �0.27Children given increased fluids (%) 9.4 18.2 7.4 �0.10Children not given ORS/recommended home fluids/increased fluids (%) 54.9 46.7 49.7 �0.25Feeding practices: amount of liquids offered to children (%)

More 18.2 7.4 �2.16Same as usual 43.3 54.5 2.24Less than usual 33.1 35.9 0.56None 5.2 2.0 �0.64Do not know or missing 0.2 0.0 0.0

Feeding practices: amount of food offered to children (%)More 6.3 1.9 �0.88Same as usual 34.2 34.7 0.10Less than usual 31.1 34.9 0.76None 4.8 5.6 0.16Never gave food 23.3 0.3 �4.6Do not know or missing 2.0 0.0 0.0

AARI, average annual rate of improvement; ORS, oral rehydration solution.



Tab

le8.

Summarytableof

findings

from

review

ofevidence

oninfant

andyoungchild

feedingduringandaftercommon

childho

odillnessesinSouthAsia

(1990–2014)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

Agh

aetal.,2007

Pak

istan

Diarrhe

aARI

NA

-88%

mothe

rscontinue

dfluids,

-Con

tinue

dfeed

ing:17%

forDiarrhe

a&

56%

for

pneu

mon

ia,

NA

NA

NA

NA

-11.7%

mothe

rsgave

less

fluidfor

diarrhea

and

lesser

for

pneu

mon

ia,

-Lessfood

:43.9%

child

ren(diarrhe

a)an

d83%

with

pneu

mon

ia,

-Caregiversare

less

resistan

tto

giving

morefluids

than

tofood

(diarrhe

a).T

hisis

dueto

emph

asis

offluids

than

food

inmed

iacampa

igns.

-Mothe

rsgave

“butter”

tohe

lpcure

diarrhea.

Ahm

edetal.,

1992

Ban

glad

esh

Diarrhe

a-E

BFisincreased

forchild

ren<

1yearsfrom

14.8%

to35.2%,

NA

-22%

hadno

rmal

family

diets,

-50%

mothe

rswith

held

somefood

belie

ving

-“So

me

food

scause

diarrhea,o

thers

increase

freq

uency

ofloosemotion,

&with

holdingor

adding

somefood

curesillne

sses.”

-Eldersin

the

family

advised

mothe

rson

care

ofsick

child

.

NA

NA

-Mothe

rspa

rtially

BFde

creased

62.5%

to43.2%,

-23.7%

mothe

rsbe

lieved

that

with

holdingor

adding

certainfood

scan

cure

diarrhea.

-Increasein

exclusiveBFdu

eto

with

holdingof

othe

rfood

s.-T

hese

child

ren

weregivenspecial

diets.

Bad

rudd

inetal.,1991

Pak

istan

Diarrhe

a->

95%

BF

continue

d.NA

-With

holdingCF:N

one,

-Buffalo

milk

common

lygiven,

NA

NA

NA

-25%

decreasedfood

intake

dueto

poor

appe

titean

dde

creased

food

intake

,

-Hom

eremed

ies,

herbal

med

icines

&teas

weregivento

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

child

renwith

diarrhea.

-Nature&

amou

ntof

fluids

&food

svaried

accordingto

disease

intensity

&du

ratio

n.Bad

rudd

inetal.,1997

Pak

istan

Diarrhe

a-~

98%

BF

continue

d.NA

NA

NA

NA

-46%

doctors

prov

ideno

nutrition

alad

vice,

-Treatmen

tgiven

with

expe

nsive

med

ications

&intraven

ousfluids.

NA

Becke

retal.,

1991

Ban

glad

esh

Diarrhe

aFever

NA

NA

-Foo

drestriction

common

NA

NA

NA

NA

Ben

akap

pa&

Shivam

urthy,

2012

India

ARIFever

-97%

BF

continue

d,NA

-57%

continue

dCF,

“Spe

cial

diets”

-19%

gave

home

remed

ieson

elde

rs’

advice.

-Doctors

aske

dto

avoid"cold"

food

,lik

ecurds,bu

tter

milk

,fruitjuices

andba

nana

sin

pneu

mon

ia(18%

).Fever:avo

idrice

–

15%,

NA

-3%

increasedBF,

-12.5%

dilutedtheCF;

70.5%

nochan

gesin

consistency,

-Firmly

rooted

belie

fsab

out“

hot”

and“cold“

food

slead

torestriction

offood

availableat

home,

-38.2%

decreased

BF,

-3%

stop

pedBFas

they

belie

vedthat

illne

sswou

ldbe

tran

smitted

tothe

child

,

-43%

caregivers

redu

ced

CF,

-Reasons

forde

creased

feed

s:child

istired

,”or

“ child

cann

otdigest

during

illne

ss.

-Preferred

food

swere‘id

li’(26.41%),rice

(18.46%)an

dbread(16.98%).

17%

-no

preferen

ce.O

ily(49%

)food

s,spicy

food

s(45.28%)an

d

-Reasons

for

decreasedBF:

“child

cann

otsuck”;or

”Mothe

rissick“.

-6%

restrictdiet

torice

andbu

tter

milk

(diarrhe

a),

-62%

:not

torestrict

anykind

offood

andto

follo

w

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

food

considered

as"cold"

were

avoide

d.

theusua

ldiet

during

recovery.

Bha

rtietal.,2006

India

Pne

umon

iaNA

NA

-Whe

nchild

renweresick

with

pneu

mon

ia,the

rewerefeed

ingrestrictions

inalargenu

mbe

rof

cases.

NA

16.5%

soug

htad

vice

from

unqu

alified

practitione

rs.

NA

NA

Bhu

iya&

Streatfield,

1995

Ban

glad

esh

Diarrhe

aFever

-BFiscontinue

din

amajority,

NA

-~50%

continue

dCFfor

diarrhea

&fever,

NA

-Con

sulting

trad

ition

alhe

alth

care

prov

iderswas

quite

common

.

-100%

doctors

prov

ideno

nutrition

alad

vice,

NA

-Nomothe

rrepo

rted

increase

inBF,

-39%

redu

cedan

d10%

discon

tinue

dCF,

-16%

redu

cedBF,

-Non

egave

moreCF,

-Dep

ending

onillne

ss,practition

ers

advisedon

food

sto

eato

rrestrict.

-Adv

iceby

doctors

mainlyon

med

icine

oruseof

ORS

(diarrhe

a):9%,

-Red

uctio

nin

BF,

high

estfor

fever+

coug

h,fever&

diarrhea,

-Reasons

for

discon

tinuing

CF:(1)

refusaltoeat/an

orexia

(2)considered

harm

ful

(3)im

positio

nby

caregiver,

-5-10%

advisedto

redu

ceor

stop

feed

ingde

pend

ing

ontheillne

ss.

-Reasons

toredu

ceor

discon

tinue

BF

are:“refusalto

eat”

or“con

side

red

harm

ful”.

-Indiarrhea,normalfood

isbe

lievedto

beha

rmful.

Das

etal.,2013

Ban

glad

esh

Diarrhe

aNA

-61.3%

gave

sameam

ount,

-Nochild

was

givenmore

food

,NA

-39.5%

mothe

rswith

0–11

mba

bies

and20%

mothe

rswith

1–2ychild

ren

soug

htad

vice

from

uncertified

.trad

ition

alprov

iders.

NA

NA

-10.8%

offered

less,

-71.4%

gave

same

amou

nt,

-27.6%

gave

homem

adefluids

likethin

watery

porridge

ofmaize,

rice,o

rwhe

at,

soup

,sug

arsalt

-28.7%

gave

less

food

,-Y

oung

er0-1-ywere

encouraged

todrink/eat

more,

-Few

olde

rchild

ren(11–

24m)wereen

couraged

toeatm

ore,

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

water

solutio

n&

yogu

rt.

Ansarieta

l.,2009

Nep

alDiarrhe

aNA

Few

mothe

rsgave

morefluids.

Few

mothe

rsgave

more

food

.NA

NA

NA

NA

Dha

dave

etal.,

2012

India

Diarrhe

a-8

7.2%

continue

dBF,

NA

-78.6%

didno

trestrict

CF,

-55.7%

ofmothe

rsgave

homeba

sed

care.

NA

NA

NA

-8.5%

BFmore,

-21.4%

restricted

CF,

-4.3%

BFless

/stop

ped.

-Nomothergave

more

CF.

Don

greetal.,

2010

India

Diarrhe

aFever

ARI

-69.7%

continue

dBF.

-~50%

continue

dfluids,

-Red

uced

CF:50%

,Sp

eciald

ietsgiven

tosick

child

ren

includ

e:

-5.7%

mothe

rswen

tto“faith

healers”.

NA

NA

-73%

continue

dBFchild

ren(<

1y)

compa

redto

75%

with

child

ren>1y,

-43.5%

<1y

and

53.9%

>1year

olds

weregiven

extrafluids.

-For

child

renwith

diarrhea

only

dryfood

itemsaregivento

eatto

redu

cestress

onba

by’s

stom

ach&

thefreq

uency

ofloosestoo

l,

-Foo

dite

ms

containing

oil&

sour

food

were

avoide

d:lead

sto

difficulty

inbreathing&

cause

coug

h,

-73.2%

working

mothe

rscontinue

dBF.

-Few

mothe

rsrespon

ded

that

child

renha

dredu

ced

appe

tite&

eatless.

-Alargenu

mbe

rof

sick

child

renwere

givenhe

rbal

tea,

hone

y,ging

eretc.

toprov

iderelie

ffrom

coug

h.

-Morechild

ren<

1y

givenextraCFcompa

red

tochild

ren>

2y,

-Hot

food

s(suchas

papaya,egg,app

le,

chikku

)&coldfood

s(suchas

curd,

banana,guava,

pomegranate,lem

on&

custardapple)

wereavoided,

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

Low

erprop

ortio

nof

child

renfrom

sche

duled

tribes/n

omad

ictribes

givenincreasedCF.

Med

icines,syrup

,injections

&tablets

arepreferredov

erho

meremed

ies.

Giri&

Pha

lke,

2014

India

Diarrhe

a-6

0%continue

dBF,

NA

-91%

continue

dCF,

-71%

:coldfood

berestricted

incold/

coug

h,

NA

NA

NA

-21%

decreased

BF,

-26.5%

:decreased

CF,

-89%

:curdbe

restricted

inARI,

-17%

increased

BF,

-9%:stopp

edCF,

-75%

:heavy

food

berestricted

indiarrhea,

-2%

stop

pedBF.

-Amon

gthosewho

continue

d:32%

preferredthinne

rconsistencyan

d8%

preferredthick

consistencyof

food

.-7

2%oily

food

berestricted

infever,

-Preferred

“spe

cial

diets”

during

illne

ss:

1)Feeding

khicha

di(81.5%

),milk

(67.5%

)&

biscuits

(59%

)forARI,

2)Ban

ana(95%

),sago

(92.5%

)&rice

water

(89%

)du

ring

diarrhea.

Gup

ta&

Gup

ta,

2000

India

Diarrhe

aFever

->75%

continue

dBF,

-92.2%

:continue

dfluids,

NA

-Hou

seho

ldremed

iessuch

asrice

grue

l,spices,

onionjuicewere

adop

tedby

8.6%

mothe

rs.

-Mothe

r-in-la

wad

visedmothe

rson

care

ofthesick

child

,

-47.3%

mothe

rsprefer

private

doctors,

NA

-7.8%

stop

pedBF.

-7.8%:stopp

edfluids,

-8.7%

child

ren<

1yearsstop

ped

-20.4%

mothe

rsprefer

govtdo

ctors,

-Majority

mothe

rs:

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

fluids

compa

red

to6.8%

child

ren

>1yr,

-Hom

eremed

ies

weregene

rally

advised.

-15.9%

gave

home-ba

sedfluids

&ORSas

first

actio

n.The

seinclud

eread

ymad

eORS,

sugar-salt

solutio

n,Lassior

Shikka

nji.

notg

iven

nutrition

alad

vice

-71%

govt.doctors

laid

emph

asison

useof

homeba

sed

fluids/O

RSas

compa

redto

27%

private

practitione

rs.

Gup

taetal.,2007

India

Diarrhe

aARI

NA

-42%

:con

tinue

dfluids,

50%:C

omplem

entary

feed

ing(C

F)continue

dNA

-Hom

eremed

ies

werefirstlineof

treatm

ent.

NA

-20%

:stopp

edfluids,

30%:gaveho

mecook

edfamily

food

s.-4

2%gave

home-

basedfluids.

Hiran

i,2012

Pak

istan

Diarrhe

aNA

NA

-CFrestrictioncommon

NA

-Mothe

rsprefer

trad

ition

alpractitione

rs.

NA

NA

-For

ARI:milk

&rice

restricted

,Huffm

an&

Com

best,1990

Ban

glad

esh

Diarrhe

a-Inmajority

BF

continue

dNA

->75%infantsoften

refuse

othe

rfood

s.NA

NA

NA

NA

Kasie

tal,

1995

Pak

istan

Diarrhe

aNA

NA

NA

NA

NA

-71%

doctorsgave

nonu

trition

alad

vice

instead

prescribed

drug

s&

ORS,-46%

doctors

prov

ided

advice

onBFan

dno

tCF,-

7%introd

uctio

nof

CFafterillne

ss.

NA

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

Kau

ret

al,

1994

India

Diarrhe

a-8

5.5%

continue

dBF,-V

eryfew

stop

pedBF.

-95.8%

:Fluids

continue

d,-3

9.6

%:F

luidsusua

lam

ounts,-5

0%:

Fluidsrestricted

,-4.1%

:Fluids

stop

ped.

-~60%:u

sual

amou

nts

CF,-3

5.4%

:restricted

CF,-~

33%

stop

pedCF

dueto

less

appe

tite,-

Dietsof

sick

child

ren

weremod

ified

.

NA

NA

NA

-CFrestriction

favo

redby

98.1%

earlier,

nowisfavo

red

by35%.Veryfew

with

held

BF.

Kau

r&

Sing

h,1994

India

Diarrhe

aNA

-Hom

emad

efluids

given,-F

ewrestricted

fluids.

-38.2%

:sam

eam

ount

CF,-6

1.8%

:CF

restricted

.

NA

NA

NA

-Health

education

prog

ramme:

Givingsaltsugar

solutio

nincreasedfrom

2%to

29.6%;

only

23.8%

gave

3-4tim

es/day,-

LessCF

improv

edfrom

55%

to29%.

Kau

shal

etal,

2005

India

Diarrhe

aFever

->75%

continue

dBF,-R

efusalto

feed

was

considered

“normal

during

illne

ss”&

asa

marke

rof

asickne

ssby

most

gran

dmothe

rs&

mothe

rs.T

hey

believedthat

health-seeking

for

poor

feed

ingcould

bede

layedfor1

day.

NA

NA

NA

-Grand

mothe

rsinflue

nced

mothe

r’s

caregiving

practices,-The

yad

visedmothe

rson

home-ba

sedcare

andpa

tterns

offeed

ing,-H

elpe

dmothe

rsto

recogn

izeda

nger

sign

ssuch

aspo

oractiv

ity,p

oor

feed

ing,

hypo

thermia,and

NA

NA

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

respiratory

distress,-

Grand

mothe

rsha

dho

mem

ade

remed

iesfor

common

ailm

ents,

someof

which

couldbe

harm

ful.

Malik

etal,

1991

Pak

istan

Diarrhe

a-7

0%continue

dBF,

NA

-78%

-87%

:weregiven

norm

alfamily

food

s.Sick

child

renalso

received

solid

&semi-solid

diet

which

was

either

"Khitchri"

orba

nana

asmen

tione

dby

more

than

halfof

the

respon

dents.

NA

NA

NA

Man

gala

etal,

2000

India

Diarrhe

a-9

2.4%

continue

dBF,-1

5.1%

BF

morefreq

uently,-

8.6%

ceased

BF.

-47%

awareof

increasedfluids.

-30%

:Con

tinue

dCF,-

2.4%

:gave“spe

cial

diets”

i.e.,cook

ing

practices

mod

ified

i.e.,

food

mashe

dor

grou

ndfood

foreasier

digestion

(mod

ificatio

nin

food

quality

),-1

6.7%

more

CF,-E

ducatio

nal

interven

tion:

increase

ofmothe

rsmod

ifyingfood

tomak

eitsoft&

more

easily

digestible

2.4%

to26.2%-Increased

feed

ing

afterillne

ss:N

one.

NA

NA

NA

After

aned

ucationa

linterven

tion

improv

emen

tsin-B

Ffreq

uency

(15.1%

to47.2%)-

Mod

ificatio

nof

CFprep

aration

(2.4%

to26.2%)-

IncreasedCF

afterillne

ss(1.2%

to20%)

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

Mem

onet

al,

2010

Pak

istan

Diarrhe

aARI

Fever

NA

-Mostm

othe

rscontinue

dfluids,-

40%:awareof

increasedfluids.

-53%

:gavemoreCFas

homecook

edmeals.

NA

NA

NA

NA

Mishraet

al,

1990

India

Diarrhe

aNA

NA

-60-66%

CFwas

givenas

usua

l,-27-30%

casesCF

mod

ified

tomak

efood

softas

norm

alfood

scan

triggerdiarrhea,-6.25%

CFwas

stop

pedto

help

child

recupe

rate

and

restrictingfood

redu

ces

stoo

ls.

-27%

to30%

cases:

speciald

ietswere

givento

sick

child

ren,-“

Hot”

food

sareavoide

d.

NA

NA

NA

Piechulek

etal,

1999

Ban

glad

esh

Diarrhe

a&

ARI

-BFcontinue

din

amajority,-22.2%

discon

tinue

dBFfor

diarrhea,-Reasons

forno

tBF&

giving

anim

almilk

:1)

Mothe

r’sbe

lieftha

tfluids

areha

rmful,

cann

otbe

absorbed

.Ano

ther

reason

for

restricting

breastmilk

2)Im

prov

emen

tsseen

indiminishe

dstoo

lvo

lume.

Diarrhe

a-Non

e:Increasedfluids,-

91.5%:con

tinue

dfluids,-0.8%

:stop

pedfluids,-

87%

Fluid

restriction

(diarrhe

a)an

d9.3%

(pne

umon

ia).

ARI-14.8%:

Restrictedfluids

until

fullrecovery.

-38%

:con

tinue

dCF,-

Non

e:increasedCF,-

>54.6%:restricted/

with

held

CF,-5

9.1%

restricted

fordiarrhea

&22.4%

forpn

eumon

ia,-

~30%

:stopp

edCFfor>

24hrs;of

thisasm

all

prop

ortio

nstop

pedun

tilchild

’srecovery,-

Mothe

rswith

hold

food

because1)

med

ical

advice;2)ow

nbe

liefo

f“k

eeping

bowelsat

rest”;

3)po

orap

petite,-

Edu

catedmothe

rsless

likelyto

with

hold

food

,-Foo

dqu

ality

mod

ified

to“cureillne

ss”.

-97%

mothe

rsgave

speciald

iettotheir

illchild

.According

totype

ofillne

ss,

certainfood

swere

avoide

dor

preferred,-Inall

illne

sses

food

slik

efish,m

eat&

vegetables

are

“avo

ided

”as

they

increase

loose

motions

orprolon

gdiseaseeffects,-

Speciald

iettocure

cold:w

arm

milk

&asyrupof

basil

“tulsi”leaves

(hot

food

s),-Sp

ecial

food

sto

cure

ARI/

-NA

-Man

ymothe

rswith

held

food

becauseof

doctors’

advice.

NA

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

pneu

mon

ia:foo

dsthat

aggravate

symptom

sof

cold

likefish,d

uckor

pigeon

meat;an

dba

nana

,green

papa

ya,g

reen

coconu

tand

some

vegetables

are

avoide

d,-S

pecial

food

sto

cure

diarrhea:raw

bana

na&

coconu

tredu

ceab

dominal

discom

fort&

diminishfreq

uency

ofstoo

ls,-Fish,

milk

,meat,or

vegetables

avoide

dby

~98%

othe

rsas

they

“increasethe

freq

uencyof

loose

motions”

(diarrhe

a).

Rashidet

al,

2001

Ban

glad

esh

ARI

NA

NA

-CFrestricted

andgiven

once

ada

y.-M

ostm

othe

rsmod

ified

child

ren’s

diets,-‘Coldfood

s’i.e.,leftov

eror

stale

food

swereavoide

das

“aggravate

pneu

mon

ia”,-O

nce

ada

y:on

lyrice

&saltor

drybread

was

prov

ided

and

-16%

mothe

rsweread

visedby

mothe

rs-in

lawto

restrict

certain

type

sof

food

,-Traditio

nala

ndallopa

thiccare

was

soug

htde

pend

ing

onthepe

rceived

NA

NA

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

arede

prived

ofvegetables

&fruits.

severity

ofthe

illne

ss.

Shah

etal,

2011

India

Diarrhe

a-5

0%BF

continue

d,-4

9.3%

decreased/

stop

ped,-R

easons

forstop

ping

BF:

Ene

rgyde

nsefood

sthat

themothe

rsconsum

eissecreted

inthebreastmilk

that

thechild

cann

otdigest.

NA

NA

NA

29%

mothe

rsconsulted

trad

ition

almed

ical

practitione

rsor

quacks.

Sharma&

Tha

kur,1995

India

Diarrhe

aFever

NA

NA

-CFiscommon

lyrestricted

.-C

Fqu

ality

ismod

ified

,-Foo

dspreferreddu

ring

coug

han

dfever:

Cold&

light

food

si.e.,curd,fruits,

rice,sago,

barley,

andbiscuits.

NA

NA

Sing

het

al,

1994

India

Diarrhe

a-B

Fcontinue

din

mostc

ases.

NA

NA

-Feeding

was

not

with

held

but

chan

gesmad

ein

thena

ture

offood

sgivenwhich

varied

byillne

sstype

,Sp

eciald

ietsgiven

indiarrhea:-1)

daliya&

khitchri

because‘in

testines

becomeweak&

child

renareun

able

NA

NA

NA

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

todigesthe

avy

food

s”;-2)

Dilu

ted

tea&

bana

nato

freq

uencyof

stoo

ls;-3)

Cow

’smilk

as“evile

yeha

dcontam

inated

breastmilk

.-4)

Foo

dsavoide

dare

“whe

atflou

rbread”

&milk

asit

is“too

heavy”;and

“Hot

food

s’lik

eap

ple,man

go,

jaggery,ne

arly

all

pulses

asthese

coulden

hancethe

freq

uency&

intensity

ofdiarrhea.

Zeitly

net

al,

1993

Ban

glad

esh

Diarrhe

aNA

NA

->36%:restrictC

Fan

d64%

gave

norm

alho

me

cook

edmeals,-

With

holdingfood

isafirst

measure

totreat

diarrhea,-10%

stop

ped

CFto

give

bowelsarest,-

<25%:gaveCFas

usua

l.-Foo

disrestricted

asmothe

rsrecogn

izethat

child

renha

veredu

ced

appe

tites

&arereluctan

tto

forcefeed

toeat.

-Spe

cial

diets:

Normalfamily

diets

aremod

ified

tosoft

food

sto

aid

digestion,-F

oods

arerestricted

/mod

ified

dueto

cultu

raln

otions

“digestiv

epo

wer

inillne

ss”,-S

oftfoo

dsgivenchild

ren<10-

mon

thsas

mothe

rsbe

lieve

“illn

ess

-Afewmothe

rsrepo

rted

trad

ition

alpractitione

rsad

visedthem

towith

hold

food

swhe

ntheirchild

haddiarrhea,

includ

ing

breastmilk

,-Mothe

rsin

lawwas

themainsource

ofad

vice

tomothe

rson

homeremed

ies.

-Health

prov

iders

prov

ided

nutrition

relatedad

vice

onfeed

ingasick

child

during

illne

ss,-A

fewmothe

rsrepo

rted

that

health

prov

iders

advisedthem

towith

hold

food

swhe

ntheirchild

haddiarrhea,

(Con

tinues)



Tab

le8.

(Con

tinue

d)

Finding

s

Disease

Breastfeeding

(BF)

Fluid

intake

Com

plem

entary

food

s(C

F)&

feed

ingpractices

Traditio

nalb

eliefs

andtheirrole

infeed

ing

practices

Com

mun

ityelde

rs/trad

ition

alpractitione

rs’

advice

Health

profession

als’

advice

Interpersona

lan

dgrou

pcoun

selling

Stud

y

Working

mothe

rsdo

not

wan

ttoforcefeed

the

child

dueto

“tim

econstraints”-S

oftfoo

dsgivenchild

ren<10-

mon

thsas

mothe

rsbe

lieve

“illn

essw

eake

nsa

child

’sdigestivepo

wer

&softdietsin

theform

ofgrue

ls&

soup

sareeasier

todigest”.

weake

nsachild

’sdigestivepo

wer

&softdietsin

the

form

ofgrue

ls&

soup

sareeasier

todigest”,-M

aterna

lor

family

’spe

rcep

tions

of“h

otor

cold

food

s”an

dits

perceived

bene

ficial/h

armful

effects.-F

ishis

avoide

d:vehicle

attractin

g“evil”

forces

that

perpetua

teillne

ss.-

Cold&

stalefood

si.e.,food

scook

edseveralh

ours

earlierare

considered

breeding

grou

nds

forba

cteria.

includ

ing

breastmilk

.

BF,

breastfeed

ing;ARI,acuterespiratoryinspectio

n;NA,n

otap

plicab

le.



studies reported that some mothers (range 6–28%)gave additional liquids/fluids to their children during ill-ness (Kaur et al. 1994; Das et al. 2013). Three studies re-ported that, in addition to water, mothers fed sickchildren home-made fluids such as watery porridgesmade from maize, rice or wheat; soups; sugar–salt–water solutions; and/or yogurt (Gupta & Gupta 2000;Gupta et al. 2007; Das et al. 2013). Six studies reportedthat mothers restricted the amount of liquids/fluidsgiven to sick children (Kaur & Singh 1994; Kaur et al.1994; Piechulek et al. 1999; Agha et al. 2007; Ansariet al. 2009; Das et al. 2013). Fluid restriction was morefrequent during diarrhoea episodes (range 4–87%)(Kaur & Singh 1994; Kaur et al. 1994; Piechulek et al.1999; Agha et al. 2007; Das et al. 2013) than during ep-isodes of fever or pneumonia (range 8.3–15%)(Piechulek et al. 1999; Gupta & Gupta 2000; Aghaet al. 2007). Only one study reported the reasons given

by mothers for restricting children’s fluid intake duringsickness (Piechulek et al. 1999); these were: (1) the be-lief that fluids could not be absorbed during diarrhoeaand thus were harmful; and (2) the perception that areduction in the stool volume in children withdiarrhoea was an improvement of the child’s condition.Two studies reported that the proportion of motherswho were aware that children need more fluids duringsickness ranged between 40% and 47% (Mangalaet al. 2000; Memon et al. 2010).

Complementary foods and feeding practices during and aftercommon childhood illnesses

Twenty studies (63%) investigated whether childrenwere fed lower, similar or larger amounts of soft,semi-solid or solid foods when they suffered fromcommon childhood illnesses. Thirteen studies reported

Table 9. Policies and programmes related to infant and young child feeding (IYCF) during and after illness in South Asian countries (1990–2014)

Afghanistan Bangladesh Bhutan India Nepal Maldives PakistanSriLanka

A national stand-alone policy for the protection,promotion and support of optimal IYCFpractices is available

Y X Y Y X X X Y

A national nutrition and/or food security policythat includes IYCF is available

Y X Y X Y X X X

The national IYCF/national nutrition/foodsecurity policy includes IYCF during and afterillness

X X X Y Y X X X

A national programme for the protection,promotion and support of optimal IYCFpractices exists

Y Y Y Y Y X Y Y

National guidelines for the protection,promotion and support of optimal IYCFpractices are available

Y Y Y Y Y Y Y Y

National guidelines for the protection,promotion and support of optimal IYCF includeIYCF during and after illness

X X Y Y X Y Y Y

The national training package for IYCFprotection, promotion and support includesIYCF during/after illness

X Y Y Y Y X X Y

A national programme for the integratedmanagement of childhood illness (IMCI) exists

Y Y Y Y Y Y Y Y

The national guidelines for IMCI includeguidance on feeding children when they are sick

Y Y Y Y X Y Y Y

The national guidelines for IMCI includeguidance on feeding children after being sick

Y Y Y Y X Y Y Y

The national training package on IMCI includesguidance on IYCF during and after illness

X Y X Y X Y X Y

Y: Yes, X: No



that children (range 25–79%) continued to be fed regu-lar family foods as usual, with no restrictions/changes infrequency and/or quantity (Becker et al. 1991;Badruddin et al. 1991; Malik et al. 1991; Ahmed et al.1992; Zeitlyn et al. 1993; Kaur et al. 1994; Bhuiya &Streatfield 1995; Gupta et al. 2007; Mangala et al.2000; Dongre et al. 2010; Memon et al. 2010; Dhadaveet al. 2012; Das et al. 2013).

However, a significant number of studies (18) indi-cated that feeding restrictions during common child-hood illnesses were frequent; these restrictionsaffected feeding frequency (4 studies: Mangala et al.2000; Dongre et al. 2010; Benakappa & Shivamurthy2012; Giri & Phalke 2014); food quality (11 studies:Mishra et al. 1990; Badruddin et al. 1991; Ahmed et al.1992; Zeitlyn et al. 1993; Sharma & Thakur 1995;Piechulek et al. 1999; Mangala et al. 2000; Agha et al.2007; Dongre et al. 2010; Benakappa & Shivamurthy2012;Giri& Phalke 2014); and/or food quantity (7 stud-ies: Kaur et al. 1994; Bhuiya & Streatfield 1995;Piechulek et al. 1999; Mangala et al. 2000; Agha et al.2007; Dhadave et al. 2012; Das et al. 2013). Food re-strictions seemed to be more common during diar-rhoea episodes (up to 83% of the mothersinterviewed) than during episodes of pneumonia andfever (up to 70% and 47% of the mothers interviewed,respectively). The reasons most commonly reported bymothers for restricting food intake when children weresick were: (1) caregivers’ perception that children hadless appetite or refused to eat/be fed (five studies:Zeitlyn et al. 1993; Kaur et al. 1994; Bhuiya &Streatfield 1995; Piechulek et al. 1999; Dongre et al.2010); (2) mothers’ reluctance to ‘force’ the child toeat (two studies: Zeitlyn et al. 1993; Bhuiya &Streatfield 1995); (3) mothers’ inability to feed the chil-dren more food/more frequently owing to resources(fuel) or time constraints (one study: Zeitlyn et al.1993); (4) mothers’ belief that illness ‘disturbed’ the di-gestive system and that feeding ‘normal’ foods washarmful to the sick child as the child’s digestive powerwas ‘diminished’ and ‘normal foods’would trigger diar-rhoea, produce cough and/or put stress on the child’sstomach (nine studies: Mishra et al. 1990; Ahmed et al.1992; Zeitlyn et al. 1993; Bhuiya & Streatfield 1995;Sharma & Thakur 1995; Mangala et al. 2000; Dongreet al. 2010; Benakappa & Shivamurthy 2012; Giri &

Phalke 2014); (5) mothers’ belief that withholdingcertain foods would help to cure diarrhoea whereasintroducing normal foods before the child was curedwould have a detrimental effect on the developmentof the child or would lead to a ‘big belly’ (threestudies: Mishra et al. 1990; Ahmed et al. 1992; Zeitlynet al. 1993); and/or (6) the belief that restricting foodintake was a first measure to manage diarrhoea athome and reduce the frequency of loose stools (fivestudies: Mishra et al. 1990; Zeitlyn et al. 1993;Piechulek et al. 1999; Dongre et al. 2010). Twostudies that measured food intake in sick children6–23months old reported that the mean energyintake of children was significantly lower than thatof healthy children and up to 70% below WHOrecommendations (Becker et al. 1991; Benakappa &Shivamurthy 2012). Two studies reported that somemothers (range 10–30%) ceased feeding their childfor 24 h or longer following medical advice, becausemothers perceived that the children had poor/noappetite and/or because social norms advised ‘to keepbowels at rest’ (Zeitlyn et al. 1993; Piechulek et al. 1999).None of the studies reported an increase in children’sfood intake (frequency, quantity and/or quality). Onlyfour studies assessed mothers’ knowledge about thefeeding needs of sick children; few mothers (range17–38%) recognized the importance of feeding sickchildren nutritious diets comprising vegetables, pulses,small fish and/or other nutrient-rich foods (Zeitlynet al. 1993; Piechulek et al. 1999; Agha et al. 2007;Benakappa & Shivamurthy 2012).

Traditional beliefs and their role in IYCF during and aftercommon childhood illnesses

Thirteen studies (41%) explored the importance of tra-ditional beliefs and perceptions on IYCF practices dur-ing and after common childhood illnesses. Nine studiesreported that when children were sick, caregivers(range 13–98%) replaced children’s usual diets with‘special diets’ owing to the belief that children’s usualdiets need to be modified to aid digestion ‘because in-testines become weak’ (Mishra et al. 1990; Ahmedet al. 1992; Zeitlyn et al. 1993; Dongre et al. 2010;Benakappa & Shivamurthy 2012; Giri & Phalke2014). Young children were often fed home remedies,



herbal medicines and teas, and ‘soft foods’ in the formof soups and gruels (Badruddin et al. 1991; Zeitlynet al. 1993; Piechulek et al. 1999; Gupta & Gupta 2000;Dongre et al. 2010; Benakappa & Shivamurthy 2012;Giri & Phalke 2014) because they were perceived to‘be lighter on the stomach’, ‘be easier to digest’, ‘reduceabdominal pain’ and/or ‘diminish the frequency ofstools’. Conversely, foods like fish, milk, meat, fooditems containing oil or even vegetables were avoidedbecause they were considered ‘difficult to digest’ or‘too heavy to digest’ (Ahmed et al. 1992; Zeitlyn et al.1993; Piechulek et al. 1999; Giri & Phalke 2014).

Seven studies (Mishra et al. 1990; Zeitlyn et al. 1993;Piechulek et al. 1999; Rashid et al. 2001; Dongre et al.2010; Benakappa & Shivamurthy 2012; Giri & Phalke2014) reported that caregivers avoided giving specific‘hot’ or ‘cold’ foods to sick children because these foodswere considered inappropriate for certain diseases.Foods commonly avoided in case of diarrhoea wereeggs/meat (range 25% to >95%), roti/chapatti/wheatflour breads (~70%) and milk (47–50%); in case ofpneumonia, commonly avoided foods were fish/duck/pi-geon (>90%) or curd/buttermilk (range 76% to 93%);in case of fever, commonly avoided foods included rice(40%) and curd/butter milk (range 60–70%). Two stud-ies reported that some caregivers (range 16–23%)avoided giving sick children foods like fish, meat oreggs because ‘they attract evil forces’ and thus theywere harmful to children (Zeitlyn et al. 1993; Piechuleket al. 1999).

Community elders/traditional practitioners’ advice on IYCFduring/after childhood illnesses

Five studies (16%) reported on the role of mothers-in-law (four studies: Zeitlyn et al. 1993; Rashid et al. 2001;Kaushal et al. 2005; Gupta et al. 2007) or other family el-ders (Ahmed et al. 1992) on decision regarding IYCFpractices when children were sick. Common advicegiven by family elders to mothers when children weresick included the following: (1) to opt for home reme-dies as a first line of treatment (Zeitlyn et al. 1993;Gupta et al. 2007); (2) to accept children’s refusal toeat/be fed as ‘normal’ and delay feeding by one day(Kaushal et al. 2005); and/or (3) to refrain from givingsick children certain foods such as fish,meat, vegetablesor milk (Zeitlyn et al. 1993). Nine studies (28%)

reported that a varying proportion of mothers (range5.3–84%) sought help from traditional/unqualifiedpractitioners when their children were sick (Zeitlynet al. 1993; Kaur et al. 1994; Bhuiya & Streatfield 1995;Rashid et al. 2001; Bharti et al. 2006; Dongre et al.2010; Shah et al. 2011; Hirani 2012; Das et al. 2013).However, only one study described the role oftraditional/unqualified practitioners on IYCF counsel-ling to mothers when children were sick (Bhuiya &Streatfield 1995). This study reported that traditional/unqualified practitioners advised mothers to restrictchildren’s food intake; however, it did not provide spe-cific details on the types of foods that a mother shouldavoid when her child was sick.

Health professionals’ advice on IYCF during and after commonchildhood illnesses

Six studies (19%) investigated the role of health profes-sionals in providing IYCF advice to mothers when chil-dren were sick (Zeitlyn et al. 1993; Bhuiya & Streatfield1995; Kasi et al. 1995; Badruddin et al. 1997; Piechuleket al. 1999; Benakappa & Shivamurthy 2012). In gen-eral, health professionals gave little or no advice tomothers on how to feed their children during or afterthe illness episode: three studies reported that healthproviders (range 46–100%) advised mothers to con-tinue breastfeeding (Bhuiya & Streatfield 1995;Badruddin et al. 1997; Piechulek et al. 1999); two studiesreported that health providers (range 9–71%) advisedmothers to give oral rehydration solution/home-basedfluids to infants and young children suffering from diar-rhoea (Bhuiya & Streatfield 1995; Kasi et al. 1995). Nostudy reported that health providers advisedmothers toincrease fluid intake when children were sick. Similarly,no study reported that health providers advisedmothers to encourage their sick children to eat soft, var-ied and favourite foods during illness, as recommendedby WHO (WHO 2003a, 2003b). Conversely, two stud-ies (Zeitlyn et al. 1993; Bhuiya & Streatfield 1995) re-ported that health providers advised mothers(proportion not reported) to withhold breast milk andfoods such as rice and buttermilk (in case of diarrhoea),rice (in case of fever) or cold foods like curd, butter-milk, fruit juices and bananas (in case of pneumoniaor acute respiratory infections). Two studies reportedthat health professionals (range 7–62%) advised



mothers to feed their children soft and semi-solid foodsonly after children had recovered from the illness (Kasiet al. 1995; Benakappa & Shivamurthy 2012).

Interpersonal and group counselling on IYCF during/aftercommon childhood illnesses

Three studies (9%) – all in India – reported the impactof behaviour change communication interventions onmothers’ IYCF practices when children had diarrhoea(Kaur & Singh 1994; Kaur et al. 1994; Mangala et al.2000). Two studies reported the impact of home visitsand group counselling by trained community healthworkers. In these studies, the proportion of mothersgiving ‘less than usual’ amounts of food to their sickchildren declined from 98% to 35% and from 55% to29% (Kaur & Singh 1994; Kaur et al. 1994). The thirdstudy assessed the impact of cooking demonstrationsusing locally available foods and interpersonal counsel-ling sessions onmothers’ IYCF practices when childrenwere sick (Mangala et al. 2000). The results of the inter-vention indicated the following: (1) the proportion ofmothers who breastfed more frequently while childrenhad diarrhoea increased from 15% to 47%; (2) theproportion of mothers who modified family foods tomake them soft and digestible (i.e. more palatable)increased from 2% to 26%; and (3) the proportion ofmothers who fed their children additional food for atleast 2weeks after the diarrhoea episode increasedfrom 0% to 20%.

Review of national policy and programmeframeworks for infant and young child feedingduring and after common childhood illnesses

We reviewed national policy and programme docu-ments to assess whether national frameworks formaternal and child nutrition integrate IYCF duringand after illness. In addition, we conducted interviewswith 13 key informants to document the existingnational programmes that protect, promote andsupport optimal IYCF practices for children duringand after illness (Table 9).

Five of the eight countries have a national IYCF pol-icy, either as a stand-alone policy framework on infantfeeding or as part of a larger policy framework onnutrition/food security. However, only two countries –

India and Nepal – have integrated the feeding needsof children during and after illness in their IYCF policyframework.

All countries have national guidelines on IYCF,and seven countries have a national programme forthe protection, promotion and support of optimalIYCF. However, only five countries include in theirnational IYCF guidelines guidance on how childrenshould be fed during and after illness, and only fivecountries have developed a training package onIYCF for programme staff that includes IYCF forchildren during and after illness.

All countries have a national programme for theintegrated management of childhood illnesses (IMCI);six countries have national IMCI guidelines thatinclude guidance on feeding children during and after ill-ness; however, only four countries have developed anIMCI training package that includes guidance on howto feed children when they are sick and after being sick.

Discussion

We conducted a comprehensive review of the availableevidence on IYCF practices during and after commonchildhood illnesses – diarrhoea, fever and pneumonia– in South Asia (1990–2014) to inform policy formula-tion, programme design, advocacy and research priori-tization to protect, promote and support optimal IYCFpractices during and after common childhood illnessesin South Asia post 2015.

Demographic Health Survey data on IYCF duringcommon childhood illnesses were available only forBangladesh, India, Nepal and Pakistan, which arehome to ~96% of the children under 5 years of age inSouth Asia (UNICEF 2015). Similarly, the 32 publica-tions that met the inclusion criteria of our reviewfocused on these four countries. Furthermore, theavailableDHS data in these four countries were limitedto IYCF during diarrhoea episodes. No survey datawere available on IYCF practices after episodes of diar-rhoea or during/after episodes of fever or pneumonia.Similarly, the published research was primarily focusedon IYCF practices during diarrhoea and to a lesserextent during fever or pneumonia episodes. Researchevidence on IYCF after common childhood illnesseswas practically inexistent.



Demographic Health Survey data indicate that in thecountries included in the analysis, children 0–23monthsold suffer from common childhood illnesses frequently,as nearly one-third of the mothers/caregivers reportedthat their children had suffered from diarrhoea or pneu-monia in the 2weeks prior to the survey. These findingsare in line with reports indicating that 39% of childdeaths in South Asia are due to diarrhoea and/or pneu-monia (UNICEF 2012). Importantly, DHS data indicatethat in all the countries included in our review, the occur-rence of diarrhoea, pneumonia and fever was lowestduring the exclusive breastfeeding period (0–5months)and highest during the early complementary feeding pe-riod (6–11months). This is most likely due to thewell-documented protective benefits of exclusive/predominant breastfeeding in the first 6months of lifeand the higher levels of infection in late infancy and earlychildhood due to children’s increased intake of comple-mentary foods and fluids that may be contaminated aswell as the ingestion of faecal bacteria throughmouthingsoiled fingers or household items when children begin tocrawl and explore their environment (Kosek et al. 2003;Dewey & Mayers 2011; WHO 2013).

Our review shows that in South Asia, IYCF behav-iours and practices during common childhood illnessesare far from optimal. Most infants and young childrencontinue to be breastfed when they are sick; however,few children (<20%) are breastfed more frequently asrecommended. Studies in other settings have reporteda similar practice, as most mothers continue tobreastfeed their sick children without altering the num-ber of nursing episodes, total amount of time of sucklingor energy derived from breast milk (Hoyle et al. 1980;Brown et al. 1990;Martz &Tomkins 1995; Brown 2003).

Similarly, most sick children continue to be fed fluids.However, few children (range 7.4–21.7% in Pakistanand Bangladesh, respectively) were fed fluids morefrequently as recommended. Mothers’ awarenessabout children’s need for more fluids during sicknessis low. This evidence is in line with reports indicatingthat in developing countries, less than a quarter(22%) of children are fed more fluids during illness(UNICEF/WHO 2009). Conversely, a significant pro-portion of mothers/caregivers in Bangladesh (26.7%),Pakistan (37.9%) and India (42.2%) fed their sick chil-dren less fluids than usual or no fluids at all in contrast

with reports from other countries (Bani et al. 2002;Saha et al. 2013).

We find that food restrictions are frequent. Manychildren were fed lower quantities and/or less fre-quently when they were sick. As many as 36% ofmothers/caregivers in Bangladesh, 41% in Pakistanand 43% in India reported that they fed their childrenless food than usual or no food at all during the last di-arrhoea episode. Only one-third (34%) of the mothers/caregivers in India to about half (55%) in Nepal re-ported that they fed their children same/similaramounts of food as usual during the diarrhoea episode.Studies in Latin America have indicated that anorexiais an important factor in the reduction of children’sdietary intake during illness (particularly whendiarrhoea or fever are present) as mothers/caregiverstend to give in when sick children send a ‘food reject’signal (Bentley et al. 1991, 1995). The combined effectsof anorexia and tradition-driven withdrawal of comple-mentary feeding during common childhood illnessescan be devastating (Scrimshaw & Sangiovanni 1997).

Our review indicates that in South Asian countries,mothers’/caregivers’ knowledge about the feedingneeds of sick children is limited and that feeding prac-tices are often guided by traditional beliefs and normsthat encourage the use of ‘special’ foods/diets to replace‘usual diets’ when children are sick. Similarly, manycaregivers seem to avoid giving certain ‘hot’ or ‘cold’foods to sick children because these foods are consid-ered inappropriate for specific diseases. Studies havereported that deeply held beliefs and traditionsdetermine the types of foods or preparation methodsthat are ‘healthy’ or ‘unhealthy’ for sick children, whenand what types of complementary foods are given tochildren and how to feed children who are sick and/ordo not want to eat. These beliefs are heavily influencedby the individuals who surround mothers – that is,husbands, mothers-in-law, grandmothers and otherfamily/community members – and the health care pro-viders upon whom caregivers depend for support(Martz & Tomkins 1995; Stewart et al. 2013).

Care-seeking practices in South Asia are said to bebelow global estimates for low-income and middle-income countries (Walker et al. 2012). However, thelatest DHS data available for the countries included inour review indicate that a significant proportion of



mothers/caregivers (ranging from 30% to 84%depend-ing on country and illness) took their sick children formedical advice during the last episode of diarrhoea,fever or pneumonia. Our review shows that fewpublished studies have investigated the quality ofhealth providers’ counselling on IYCF to mothers/caregivers when children are sick. The evidencereviewed indicates that when mothers/caregivers seekadvice/support in the primary health care system,health professionals provide little or no advice tomothers/caregivers on how to feed children when theyare sick/convalescent. In general, health providers donot advise mothers to increase children’s fluid intakeand encourage sick children to eat soft, varied andfavourite foods during illness, while increasingbreastfeeding frequency as is recommended. More-over, there is indication that a non-negligible propor-tion of health providers advise mothers to withdrawbreast milk and/or specific nutritious foods/all comple-mentary foods until children recover from illness.

Studies in other low-income and middle-incomecountries have found the following: (1) health workersdo not maximize their contacts with women andchildren to support optimal IYCF; (2) there is poorknowledge among health practitioners on how to feedand/or manage sick children and manage children withpoor appetite; (3) even when a national normative andguidance frameworks on IYCF for sick children are inplace, a limited proportion of paediatricians and familypractitioners follow them; and (4) the quality of careand advice among private practitioners is not necessar-ily better than among public health system providers(Bezerra et al. 1992; Bojalil et al. 1998; Baker et al.2013; Lutter et al. 2013).

Conclusion

Diarrhoea and pneumonia remain the leading infec-tious causes of childhood morbidity and mortality inSouth Asia (Fischer et al. 2013). Compelling evidenceindicates that childhood diarrhoea and pneumoniadeaths are avoidable and that scaling up optimalfeeding behaviours and practices in combination withappropriate case management can avoid most of thesedeaths (Bhutta et al. 2013).

Our review shows that information of IYCF behav-iours and practices during illnesses in South Asia islimited while information of IYCF after common child-hood illnesses is virtually inexistent. The evidencereviewed indicates that in South Asia, IYCF behav-iours and practices during common childhood illnessesare far from optimal. In general, sick children continueto be breastfed. However, few are breastfed morefrequently to compensate for the additional fluid andnutrient requirements associated with illnesses, whilea significant proportion of children is breastfed lessfrequently than usual. Restriction or withdrawal ofcomplementary foods during illness is frequent becauseof children’s anorexia (perceived or real), poorawareness by caregivers’ about the feeding needs ofsick children, traditional beliefs and behaviours,and/or suboptimal counselling and support by healthworkers. As a result, many sick children are fed lessfrequently and/or lower quantities of complementaryfoods.

Mothers/caregivers often turn to family/communityelders and traditional/non-qualified practitioners toseek advice on how to feed their sick children. Thus,traditional beliefs and behaviours often guide the useof ‘special’ feeding practices, foods and diets for sickchildren. Our review indicates that when children aresick, a significant proportion of families turn to theprimary health care system for advice and support. Ingeneral, health professionals give little or no advice tomothers/caregivers on how to feed their children whilethey are sick. However, the few intervention studiesavailable indicate that inter-personal and groupcounselling as part of primary health care can substan-tially improve mothers’ IYCF knowledge and practicesduring common childhood illnesses.

Global guidance and normative frameworks are inplace to address the feeding of sick children duringand after illness (WHO 2003a, 2003b; WHO/UNICEF2003; WHO 2005). All the countries included in ourreview have national guidelines on IYCF and a nationalprogramme for the IMCI. However, there seem to beimportant policy, guidance and capacity building gaps inthese frameworks with respect to IYCF when childrenare sick or convalescent. Our review indicates that alimited proportion of health practitioners follows allaspects of these guidance.



In light of our findings, it seems reasonable to recom-mend the following as away forward to protect, promoteand support optimal IYCF practices during and aftercommon childhood illnesses in South Asia post 2015:

1. align national policy frameworks and programmaticguidance with internationally agreed upon recom-mendations on IYCF during and after commonchildhood illnesses, with a particular emphasis ondiarrhoea, fever and pneumonia;

2. expand the DHS and National Nutrition Surveys toinclude quantitative information on IYCF duringand after common childhood illnesses, with appro-priate geographic, socio-economic and genderdisaggregation;

3. collect qualitative and quantitative information oncaregivers’ behaviours and health workers’ prac-tices related to IYCF during and after commonchildhood illnesses to identify the most importantdrivers of current behaviours/practices and bottle-necks to optimal IYCF when children aresick/convalescent;

4. build the capacity of facility-based and community-based health workers to provide mothers/caregiverswith timely and accurate information, counsellingand support on IYCF when children are sick/convalescent;

5. design and implement effective communication strat-egies that combine interpersonal communicationand mass communication to address harmful beliefsand norms with respect to the nutrient and feedingneeds of children during/after common illnesses; and

6. document the effectiveness, impact and lessonslearned of the capacity building and communicationstrategies to improve IYCF during and after com-mon childhood illnesses and their implications forprogramme scale up and universalization.

Acknowledgements

The authors acknowledge inputs and feedback to thepreliminary drafts of this paper by the following indi-viduals: Aishnath Shahula Ahmed, Anirudra Sharma,France Begin, Gayatri Singh, Isabel Vashti Simbeye,Mohsin Ali, Pravin Khobragade, Renuka Jayatissa,Sherin Varkey, Tania Goldner and Wisal Khan.

Source of funding

TheUNICEFRegional Office for South Asia providedsupport for data analysis and paper writing. This re-search received no specific grant from any fundingagency in the commercial sector.

Conflicts of interest

The authors declare that they have no conflicts of inter-est. The opinions expressed on this paper are those ofthe authors and do not necessarily represent an officialposition of UNICEF.

Contributions

VMA designed the study, KP led data analysis. Bothauthors contributed equally to data interpretation andmanuscript writing and have read and approved thefinal submission.

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