The demographic characteristics and nutrition status at birth of N = 2679 infants followed in routine household surveillance are summarized in Table 1. The mean infant age at the time of enrolment was 8 days (SD ± 7.4), and 91.6% of the infants were born at full-term. Most of the infants (58.4%) had breastfeeding initiated between 7 to 12 hours of birth, while only 236 (9.4%) infants had breastfeeding initiated within the first hour of birth. 98.3% of the infants had ever been breastfed at any point at the time of enrolment into the study. Infant anthropometry revealed that 14.7% of the infants were wasted (WHZ < -2 SD), 36.7% were stunted (HAZ < -2 SD) and 38.5% were under-weight (WAZ < -2 SD) at the time of enrolment (within a week of birth). The mean weight of the infants was 2.7 kilograms (SD ± 0.5) and mean length at time of enrolment was 48.7 centimetres (SD ± 31.9).
Table 1
Baseline characteristics of participants at enrolment (N = 2679)
Characteristics | | N |
Age in days (mean ± SD) | 8.0 ± 7.4 | 2,679 |
Child Gender | | 2,679 |
Male | 1,375 (51.3%) | |
Female | 1,304 (48.7%) | |
Facility Births | 2,184 (82.7%) | 2,641 |
Gestational age at birth (weeks) | | 2,644 |
Preterm (GA < 37 weeks) | 223 (8.4%) | |
Full-term (GA > = 37 weeks) | 2,421 (91.6%) | |
Time of initiation of BF | | 2,516 |
Within 1 hour | 236 (9.4%) | |
Between 1–6 hour | 1,469 (58.4%) | |
Between 7–12 hour | 350 (13.9%) | |
>12 hours | 461 (18.3%) | |
Ever Breastfeed | 2,501 (98.3%) | 2,544 |
Weight, kg (mean ± SD) | 2.7 ± 0.5 | 2,679 |
Length, cm (mean ± SD) | 47.6 ± 2.7 | 2,676 |
Weight for height Z-Score (mean ± SD) | -0.9 ± 1.1 | 2,285 |
Height for age Z-Score (mean ± SD) | -1.7 ± 1.2 | 2,659 |
Weight for age Z-Score (mean ± SD) | -1.7 ± 1.1 | 2,637 |
Malnutrition Status (%) | | |
Wasted (WHZ<-2SD) | 336 (14.7%) | 2,285 |
Stunted (HAZ<-2SD) | 976 (36.7%) | 2,659 |
Under-weight (WAZ<-2SD) | 1,016 (38.5%) | 2637 |
The prevalence of breastfeeding and complementary feeding practices across the first six months in wasting (W) and otherwise/non-wasting (NW) infants is summarised in Fig. 1. While exclusive breastfeeding was more common in the first month, predominant breastfeeding (where the infant receives breastmilk as the main source of nutrition but also receives water, juice, or other non-milk liquids) was the most prevalent type of feeding observed for infants between one and six months of age. The proportion of children not breastfed was 46.5% at 6 months of age in the wasting group, compared to 9.3% in the non-wasting group.
Figure 2 depicts the breastfeeding practices of under-weight (UW) and not-underweight (NUW) children from birth to 6 months. Initially, a higher percentage of NUW children are exclusively breastfed (63.1%) compared to UW children (38.7%), which may indicate the protective benefits of exclusive breastfeeding against underweight status. NUW children have a consistently higher rate of exclusive and predominant breastfeeding throughout the first six months. The proportion of UW children who are not breastfed at all is higher than that of NUW children from birth and increases with age, peaking at 32.9%, compared to only 7.7% of NUW children at 6 months. Additionally, UW children are more likely to be fed breastmilk with other milk right from the first month, which may reflect on parental attempts to address early concerns about their child’s failure to thrive. The prevalence of this practice decreases with age in both groups but remains higher among underweight children up to 5 months of age.
In Table 2, the comparative analysis of infant feeding practices against malnutrition status, specifically focusing on wasting and underweight conditions, revealed that for wasted infants, the average age at which wasting developed was 3.7 ± 0.9 months. Notably, infants who were wasted started other milk at a significantly younger age (1.9 ± 1.6 months) compared to their counterparts (2.3 ± 2.0 months, p = 0.003), and also began complementary feeding earlier (4.3 ± 1.2 months vs. 5.3 ± 1.2 months, p < 0.001). Exclusive breastfeeding at 3 months was lower in the wasted group (10.7%) compared to the otherwise nourished group (14.0%, p = 0.018). A similar trend was observed in underweight infants, where the initiation of other milk and complementary feeding occurred earlier (2.1 ± 1.9 and 5.1 ± 1.3 months, respectively) than in healthier infants (2.4 ± 2.0 and 5.3 ± 1.2 months, p = 0.019 for both). Furthermore, at 6 months, exclusive breastfeeding rates were lower in the underweight group (8.5% vs. 5.3%, p = 0.024) compared to the control group. These findings suggest a strong correlation between early initiation of breastmilk alternatives, lower rates of exclusive breastfeeding, and the incidence of wasting and underweight status in infants.
Table 2
Comparison of Infant Feeding Practices and Malnutrition Status
Variable | Mean/Frequency | Significance |
Wasting |
| Wasted | Otherwise | p-value |
N | 365 | 2,314 | |
Age at development of wasting (mean ± SD) | 3.7 ± 0.9 | - | - |
Duration of Exclusively Breastfeeding in months (mean ± SD) ¥ | 0.3 ± 0.8 | 0.4 ± 0.9 | 0.25 |
Age at initiation of any other milk in months (mean ± SD) | 1.9 ± 1.6 | 2.3 ± 2.0 | 0.003 |
Age at initiation of complementary feeding in months (mean ± SD) | 4.3 ± 1.2 | 5.3 ± 1.2 | < 0.001 |
At 3 months |
N | 280 | 1,657 | 0.018 |
Exclusive breastfeeding | 30 (10.7%) | 232 (14.0%) | |
Predominant BF | 152 (54.3%) | 990 (59.8%) | |
Breastfed & other milk | 94 (33.6%) | 420 (25.4%) | |
Not breastfed | 4 (1.4%) | 14 (0.8%) | |
At 6 months |
N | 30 | 1,245 | 0.19 |
Exclusive breastfeeding | 4 (13.3%) | 78 (6.3%) | |
Predominant BF | 13 (43.3%) | 732 (59.3%) | |
Breastfed & other milk | 13 (43.3%) | 409 (33.1%) | |
Not breastfed | 0 (0.0%) | 16 (1.3%) | |
Under-weight |
| Under-weight | Otherwise | p-value |
N | 1214 | 1,439 | |
Age at development of wasting (mean ± SD) | 3.9 ± 1.0 | | |
Duration of Exclusively Breastfeeding in months (mean ± SD) ¥ | 0.3 ± 0.8 | 0.4 ± 1.0 | 0.035 |
Age at initiation of any other milk in months (mean ± SD) | 2.1 ± 1.9 | 2.4 ± 2.0 | 0.019 |
Age at initiation of complementary feeding in months (mean ± SD) | 5.1 ± 1.3 | 5.3 ± 1.2 | 0.019 |
At 3 months |
N | 854 | 1,071 | 0.028 |
Exclusive breastfeeding | 102 (11.9%) | 160 (15.0%) | |
Predominant BF | 492 (57.6%) | 644 (60.2%) | |
Breastfed & other milk | 251 (29.4%) | 257 (24.0%) | |
Not breastfed | 9 (1.1%) | 9 (0.8%) | |
At 6 months |
N | 485 | 787 | 0.024 |
Exclusive breastfeeding | 41 (8.5%) | 41 (5.3%) | |
Predominant BF | 276 (57.1%) | 468 (60.1%) | |
Breastfed & other milk | 156 (32.3%) | 264 (33.9%) | |
Not breastfed | 10 (2.1%) | 6 (0.8%) | |
¥: Child considered on exclusive breastfeeding if he/she is continuously on exclusive breastfeeding with no breaks observed during follow-ups.
The results of the multivariate binomial logistic regression analysis, aimed at identifying factors influencing the likelihood of wasting in infants, are presented in Table 3. The analysis focused on the period between 4 to 6 months of age, as most cases in the sample were enrolled after the age of 4 months. A critical finding was that the odds of an infant experiencing wasting (WHZ < -2 SD) were significantly increased by four times if complementary feeding was initiated before the infant reached 4 months of age (adjusted odds ratio [AOR] = 4.14, 95% CI: 1.95–8.77; p < 0.001). Male infants had a higher unadjusted likelihood of wasting compared to females (OR = 1.56, 95% CI: 1.25, 1.96; p < 0.0001), although this factor was not adjusted in the final model. Infants not born in a medical facility had a higher adjusted odds of wasting (AOR = 2.43, 95% CI: 1.13, 5.21; p = 0.023). Mothers who did not breastfeed at all showed a higher unadjusted likelihood of their infants experiencing wasting (OR = 2.75, 95% CI: 1.42, 5.33; p = 0.003), but this factor was not included in the adjusted model.
Table 3
Binary Logistic Model for wasting children (OR, 95% CI)
Variables in the model | Unadjusted odds ratio (95% CI) | P-value | Adjusted odds ratio (95% CI) | P-values |
Sex | | | | |
Male | 1.56(1.25,1.96) | < 0.0001 | - | - |
Female | Ref. | | - | - |
Facility Birth | | | | |
No | 1.35 (1.03, 1.78) | 0.032 | 2.43 (1.13, 5.21) | 0.023 |
Yes | Ref. | | Ref. | |
Did you ever breastfeed | | | | |
No | 2.75 (1.42, 5.33) | 0.003 | - | - |
Yes# | Ref. | | - | - |
Time of initiation of BF | | | | |
Within 1 hour | 1.06 (0.68, 1.64) | 0.8 | - | - |
Between 1–6 hour | 0.92 (0.68, 1.24) | 0.566 | - | - |
Between 7–12 hour | 0.91 (0.61, 1.36) | 0.654 | - | - |
> 12 hours | Ref. | | - | - |
Gestational age at birth (weeks) | | | | |
Preterm (GA < 37 weeks) | 1.28 (0.89, 1.86) | 0.189 | - | - |
Full-term (GA > = 37 weeks) | Ref. | | - | - |
Age at initiation of complementary feeding in months | | | | |
< 4 | 4.28 (2.04, 8.96) | < 0.001 | 4.14 (1.95, 8.77) | < 0.001 |
> 4 | Ref. | | Ref. | |
Duration of Exclusively Breastfeeding in months¥ | 0.92(0.81,1.06) | 0.248 | - | - |
Age at initiation of any other milk in months | 0.88 (0.81, 0.96) | 0.003 | - | - |
¥: Child considered on exclusive breastfeeding if he/she is continuously on exclusive breastfeeding with no breaks observed during follow-ups.
Table 4 indicates the results of the binary logistic regression analysis examining the factors associated with underweight status in infants. A significant finding from the analysis is the gender disparity; male children were found to have a higher likelihood of being underweight compared to female children, with an adjusted odds ratio of 1.64 (95% CI: 1.18, 2.29; p = 0.003). Children not born in a medical facility faced a higher risk of being underweight, with an adjusted OR of 1.74 (95% CI: 1.13, 2.71; p = 0.013). A significant relationship was also observed between breastfeeding practices and underweight status: children who were breastfed within the first hour of birth showed a reduced unadjusted likelihood of being underweight (OR = 0.62, 95% CI: 0.45, 0.86; p = 0.004), as did those who were breastfed between 1–6 hours after birth (OR = 0.73, 95% CI: 0.59, 0.90; p = 0.003). However, these factors were not included in the adjusted model.
Preterm birth (gestational age < 37 weeks) showed a marginal association with underweight status in the adjusted model (AOR = 1.66, 95% CI: 0.93, 2.95; p = 0.087). Additionally, initiating complementary feeding before 4 months of age was associated with an increased risk of underweight status, both in unadjusted (OR = 1.98, 95% CI: 1.23, 3.21; p = 0.005) and adjusted models (AOR = 1.97, 95% CI: 1.20, 3.22; p = 0.007). The duration of exclusive breastfeeding and the age at initiation of any other milk also showed significant associations with the underweight status in the unadjusted model, indicating their potential influence on child nutrition and growth, thereby highlighting the importance of timely initiation of breastfeeding, the location of birth, and the timing of introducing complementary feeding as critical factors in preventing underweight status among children.
Table 4
Binary Logistic Model for under-weight children (OR, 95% CI)
Variables in the model | Unadjusted odds ratio (95% CI) | P-value | Adjusted odds ratio (95% CI) | P-values |
Sex | | | | |
Male | 1.41 (1.21,1.64) | < 0.0001 | 1.64 (1.18,2.29) | 0.003 |
Female | Ref. | | - | - |
Facility Birth | | | | |
No | 1.58 (1.29,1.94) | < 0.0001 | 1.74 (1.13,2.71) | 0.013 |
Yes | Ref. | | Ref. | |
Did you ever breastfeed | | | | |
No | 1.92 (1.03,3.61) | 0.041 | - | - |
Yes# | Ref. | | - | - |
Time of initiation of BF | | | | |
Within 1 hour | 0.62 (0.45,0.86) | 0.004 | - | - |
Between 1–6 hour | 0.73 (0.59,0.90) | 0.003 | - | - |
Between 7–12 hour | 0.80 (0.60,1.05) | 0.109 | - | - |
> 12 hours | Ref. | | - | - |
Gestational age at birth (weeks) | | | | |
Preterm (GA < 37 weeks) | 1.34 (1.01,1.78) | 0.04 | 1.66 (0.93,2.95) | 0.087 |
Full-term (GA > = 37 weeks) | Ref. | | Ref. | - |
Age at initiation of complementary feeding in months | | | | |
< 4 | 1.98 (1.23,3.21) | 0.005 | 1.97 (1.20,3.22) | 0.007 |
> 4 | Ref. | | Ref. | |
Duration of Exclusively Breastfeeding in months ¥ | 0.91 (0.84,0.99) | 0.036 | - | - |
Age at initiation of any other milk in months | 0.93 (0.88,0.99) | 0.019 | - | - |
¥: Child considered on exclusive breastfeeding if he/she is continuously on exclusive breastfeeding with no breaks observed during follow-ups.