The rates of exclusive breastfeeding vary substantially across the populations and even between different regions within the same country (1 % − 89 %) [17]. The current study revealed unexpectedly high rate of EBF in sampled Egyptian mothers (55.8 %). This was approximately 1.5 to 5 times higher than the rates reported from Egypt (29.9 %, 32 %, and 9.7 %) [18–20], Africa (35.7 %) [21] and other Arab countries (25 % and 16.3 %), respectively [22, 23]. Although, our prevalence exceeded the global and regional trends (39 %) in the developing countries [24], higher rates were reported from recent studies conducted in Egypt (65 %) and Northwest Ethiopia (74.1 %) [25, 26]. Employing different survey strategies, coexistence of various perspectives, cultural norms and traditional beliefs may have influenced such difference. Moreover, participants were predominately non-working mothers who were full-time housewives (n = 139, 59.1 %), supposed to spend considerable amount of time taking care of their infants. This observation wasn’t identified as being associated with EBF in our study (p = 0.085), however it was in agreement with other researches from the Middle East [27] and Asia [28] where the working mothers were more likely to abandon EBF.
Inconsistent with previous studies from Egypt [18, 20, 23, 25], we identified maternal age of 25–29 years (68.3 %) as being the only predictor correlated with EBF (p < 0.001). A survey of 349 Latin mothers found that younger mothers were more likely to exclusively breastfeed their infants [29]. Although not statistically significant, most of those mothers (n = 154, 98.1 %) had earned a high education credentials. Similar results were also observed in studies from Egypt and other developing countries [18, 19]. This education level may influence the rate of EBF through increasing knowledge about its benefits and improving mothers ‘attitudes; which will eventually improve their practices.
Although Islamic teachings of Koran recommend breastfeeding until 2 years of age [30], infant feeding is still a subject of intense debate within the Egyptian community [31]. Based on our results, more than nine-tenths of the respondents (91.1 %) exhibited suboptimal feeding practices. For example, only a small proportion of mothers (n = 18; 11.6 %) practiced effective breastfeeding in terms of positioning and attachment as evaluated by WHO B-R-E-A-S-T- Feed Observation Form [32], with the majority of them aged 30–35 years (n = 17; 94.4 %). Eighty-one mothers, comprising more than one third of the total respondents (34.5 %), prematurely terminated breastfeeding at a mean infant age of 3.3 (SD = 5.9) months. Perceived insufficient milk-supply, maternal concerns about infant weight gain and infant breast refusal were the most frequent reasons addressed for discontinuation of breastfeeding, a finding corroborated by other studies [33, 34].
The current study investigated infant and parental socio-demographic factors as determinants of breastfeeding cessation. Consistent with other studies [33, 35], we found maternal age, occupation and residence had significant negative impact on mothers’ infant feeding decisions. This highlights the importance of antenatal health educational programs as a key entry-point for improving future trends in maternal and infant nutrition. Orientation of maternal stressors existing within a broader social context such as working and living conditions could combat the early termination of breastfeeding.
The last three decades have seen a remarkable increase in using bottle-feeding, particularly in developing countries. This use has drastically compromised breastfeeding either by being a substitute or complementary to breast milk [36]. This finding was reported in 24.7 % (n = 58) of the study participants, predominantly in middle-class mothers (n = 48, 82.2 %) residing in urban areas (n = 38, 65.5 %). Similar trends have been identified in a recent study which reported higher rates of artificial milk consumption in low-income countries compared to middle-income ones [37]. Despite significant global progress in implementing International Code Marketing of Breast-milk Substitutes, several factors such as innovative long-term and in-depth strategies, particularly digital marketing along with constraints in enforcement of the Code under various national laws have been linked to increased prevalence of bottle-feeding [38]. Moreover, Egyptian Government has maintained a budget of ~ 50 million US dollars for subsidizing infant milk formulas with subsequent decline in EBF rate [39]. As noted in earlier study [40], we found that 58.6 % (n = 34) of bottle-fed infants had non-working mothers. This may be related to the relatively higher number of housewife participants in the current survey.
Solid, semi-solid and soft foods were introduced by almost all participants at the time of the study. Significantly, more than half of study infants (58.3 %) started receiving complementary food at ≥ 6 months of age (p < 0.001) in addition to breast milk. Consistent with other studies [41, 42], we recognized socio-cultural factors as major determinants of complementary feeding practices. For example, 73.4 % of the study mothers had acknowledged giving herbs, plain water, non-milk fluids and dropping night milk feeds as the most common inherited beliefs frequently practiced in rural and urban settings.
Family members, relatives and friends played a fundamental role in shaping the process of weaning in terms of onset, sources and contents (n = 75.3 %, p < 0.001). These practices are probably similar in most developing countries from Africa and Asia [39, 41, 42]. Yet, there was ample evidence that the health care providers had influenced the maternal attitudes towards infant feeding displayed in 61.7 % of study mothers. Recent studies found that the grandmothers and healthcare providers have a significant impact which is more likely to be associated with adverse infant and maternal health outcomes [43, 44]. This poses a challenge for setting multicomponent interventions tailoring messages for mothers, household members, particularly older adults, and primary health care personnel.
For all children younger than 2 years of age, growth and development entail high nutrient needs; therefore, complementary foods should be optimal in terms of affordability, diversity and being nutrient-rich [45]. In the majority of developing countries, commercial fortified infant foods are often far away and purchasing those products is beyond the mean of the poor [3], however, we found that diets predominantly based on home-made recipes were significantly consumed lower than commercially-prepared ones (p < 0.001).
Based on the analysis of daily intakes from all food sources, this study revealed that the infants aged 5–24 months of age appeared to have inadequate dietary intake except for calcium, vitamin B2 and vitamin C which significantly met their recommended reference values (p < 0.001). The mean energy, proteins and fat daily consumption was substantially higher than recommended (p < 0.001), a finding found to be consistent across different countries around the world [47]. An increased consumption of dairy products (n = 209, 88.9 %) or milk, including cow’s milk and formula, put infants, particularly the 1-year old, at risk of being overweight, a prediction confirmed in 52.7 % of infant participants (n = 124) [46].
Consistent with previous study [47], we reported a considerable percentage of infants exceeding the Tolerable Upper Intake levels for sodium, potassium, magnesium, phosphorus and zinc.
In the same context, consumption of carbohydrates, fibers, iron, selenium, vitamins A and B1 was below recommendations for the vast majority of infants (p < 0.001). This may be attributed to the fact that fiber is linked only to carbohydrate portion of the diet which is reduced in the Arab Middle East diet. Moreover, a study conducted in Lower Egypt demonstrated lack of dietary diversity and daily meal frequency that might contribute to such insufficient intake [48]. Based on previous studies, consuming recommended portions from different food groups instead of a specific one was associated with adequate micronutrient intake [49].
In contrast to data from other Arab countries [48, 49], fruits and vegetables were considered essential for meals commonly served to 93.6 % (n = 220) of infant participants. This dietary consumption pattern of vitamin C-rich food along with inadequate iron intake can largely explain the high prevalence rate of anemia in our study.
Similar to other studies [50, 51], undernutrition, predominantly, stunting, was prevalent across all age groups. Inadequate breastfeeding, poor weaning practices and recurrent diarrhea have been reported as risk factors for undernutrition in developing countries [50, 51].
Although these findings had identified that the Egyptian mothers may share some common features with women from other Arab countries, however, they sustain more healthy food choices.
The findings of the current study should be interpreted in view of its strengths and limitations.
The current study is cross-sectional study relying on the mothers’ memories, which may be subject to recall bias; as most of study participants were interviewed 5–24 months after childbirth. The relatively small sample size may be not sufficient to yield a good indicator for IYCF practices in Egypt. Moreover, we couldn’t evaluate all potential confounding factors that might be associated with infant feeding and weaning practices. For example, a lot of participants refused to give data on infant’s birth order and family size. The fact that many Egyptians continue to hold a strong superstitious belief in “Evil Eye”, which is so much dreaded, particularly by mothers in reference to their children, along with concerns of being interviewed in overcrowded facilities, with long queues and lack of adequate privacy may be related to such response. Nonetheless, to the best of our knowledge, few studies have been reported in Egypt investigating the daily food intake in children ≤ 2 years of age with concomitant diversity of dietary patterns observed in Egyptian community.