Nutrition is the key element regulating children’s growth, particularly during infancy. During this phase, the energy requirements are the utmost due to heightened metabolic activity aligning with rapid growth [1]. Simultaneously, the infant’s digestive system is at its most vulnerable stage where unintentional feeding inaccuracies can result in serious health complications including allergies, eczema, iron-deficiency anemia, rickets, obesity, respiratory illnesses and infant botulism, among many others [2]. The 2022 statistical data from the Oman Ministry of Health reported that among children younger than five years, 10.2% had iron deficiency, 10.6% had vitamin D deficiency, 11.2% were underweight, and 4.2% were having overweight or obesity [3].
Health organizations, including esteemed entities such as the World Health Organization (WHO) and the Center for Disease Control (CDC), have set comprehensive infant feeding guidelines and recommendations. These recommendations vary between the first and second six months of infant’s age, aligning with the dynamic developmental alteration that dictate the nutritional needs and digestive capabilities of the growing infant. The infant’s digestive system in the first six months of age is merely capable of processing human milk or modified milk, which comprises all the essential nutrients the body needs. The advantages of exclusive breastfeeding surpass the modified milk across biological, psychosocial, and cognitive domains [4], thus supporting the endorsement of exclusive breastfeeding during the initial six months. At the age of six months, the gradual incorporation of solid food should commence, marking a stage when the body has acquired sufficient mechanical and physiological capabilities such as enhanced digestive enzymes, increased stomach capacity, enhanced sitting skills, development of teeth, and improved jaw function [5, 6].
Limited breastfeeding experiences during infancy have been linked to reduced immunity and obesogenic eating behaviors [7]. Exposing the infant to a variety of food options during the second six months of life is essential for accepting and meeting the nutritional demands at a later stage of life [8]. However, early introduction of solid food has been found to increase the incidence of eczema, allergies, and respiratory infection, as well as obesity [9–11]. At the same time, food items such as honey, unmodified milk and egg whites, are refrained until the infants’ first birthday due to their association with identified health risks [12]. Bee honey, for instance, has been demonstrated to be associated with infant botulism when introduced before the age of one year [13]. The imposition of safe and healthy infant feeding practices places a considerable amount of pressure upon parents. Health care providers share that burden as they are the main source of parent’s awareness and support. Consequently, regular assessment of infant feeding practices emerges as an imperative undertaking, serving as a foundational strategy for the early identification of nutritional risks and potential concerns.
A review of the regional literature indicates a suboptimal level of adherence to the infant feeding recommendations and stresses the need for immediate measures to promote children’s healthy nutrition [14]. A Saudi study examined the infant feeding practices among mothers of infants aged between 4 to 12 months through an electronic mothers' feeding practices semi-structured questionnaire and found that only 5.3% of infants exclusively breastfeed in the first six months and 64.3% were introduced to complementary food before the age of six months [15]. In a population-based survey conducted in the United Arab Emirates, 26% of infants had exclusive breastfeeding in the first six months and 19% started complementary feeding before the age of six months [16]. Data from the Oman National Nutrition Survey (ONNS) conducted in 2017 indicated that less than a third of the mothers (29%) were exclusively breastfeeding their infants in the first six months of age [17]. Complementary food including juice, yogurt, soup and porridge were introduced to infants younger than six months with percentages ranging from 6–13%[17].
Without undermining the significance of data presented by the above studies, data about the infant feeding practices from the Middle East and Northern Africa (MENA) region is fragmented and lacks inclusiveness. Simultaneously, Arabic women living the Western countries convey needs related to culturally sensitive infant feeding services [18].
Nevertheless, infant feeding tools available in the literature lack comprehensiveness and inclusiveness to infants of different ages. The ONNS screening tool, adapted from the WHO’s STEP wise approach, focuses on the initiation of breastfeeding, exclusive breastfeeding in the first six months, and acceptable diet scores for infants aged 6 to 24 months. The acceptable diet score is calculated based on the diet diversity (number of food groups) and frequency indices in the previous 24 hours [19]. Thus, providing a snapshot of the infant feeding practices. However, it lacks specifications related to the timing of introducing certain food items, which guide healthcare providers in estimating the associated health risks.
Researchers from the United States (US) assessed the infant feeding practices through the Complementary Feeding Utility Index (CFUI). The CFUI standards evaluated the exposure to iron-rich cereal, energy-dense nutrient-poor foods, teas/broths, vegetables, fruits, sugary drinks, and breastfeeding duration. The results indicated a suboptimal intake of fruits and vegetables, increased sugary drinks, and reduced duration of breastfeeding [20]. Despite the significance of the results extracted, it lacked specifications related to the timing of introducing the food items.
Available tools put more attention on breastfeeding practices and initiation of complementary feeding in general, where they fall short in providing specifications about certain early or late infant feeding practices that are known to link with specific risks. For example, feeding infants bee honey before the age of 12 months is a common practice in the Middle East. Hence, no questionnaire has assessed the phenomenon adequately. That led to blurriness in the estimated risks for infant botulism. Thus, there is an urgent need for a rigorous, comprehensive and culturally sensitive infant feeding assessment tool. To fill the gap and contribute to estimating the infant feeding risks, this study pilot tested a newly developed infant feeding structured questionnaire that aims to provide a comprehensive description of infant feeding practices and beliefs, adherence to infant feeding recommendations, and maternal factors associated with adherence to infant feeding recommendations.