Achieving optimal breast-feeding rates is one of the most important public health goals, although achieving 6 months of exclusive breast-feeding is quite a challenge in most parts of the world, including most of Africa. In a randomized controlled trial by Ochola et al., published in this issue of Public Health Nutrition (Reference Ochola, Labadarios and Nduati1), intensive (seven sessions) home-based breast-feeding counselling significantly improved exclusive breast-feeding rates from birth to 6 months, while semi-intensive (one session) counselling significantly improved exclusive breast-feeding at 1 month only, as compared with a control group that received no counselling. The study adds to the current knowledge that regular contact at the community level could be an effective way to support established hospital-based efforts, such as the WHO/UNICEF Baby Friendly Hospital Initiative aimed at sustaining exclusive breast-feeding of infants up to 6 months of age. The search for feasible and cost-effective approaches that could have a positive impact on exclusive breast-feeding remains ongoing.
Such efforts should also be accompanied by interventions aimed at adequate and timely complementary feeding and micronutrient supplementation as necessary. It has been estimated that some 6 % of young child deaths could be prevented through optimal complementary feeding(Reference Jones, Steketee and Black2). The basic principles of complementary feeding are theoretically straightforward(3) and interventions based on these principles can improve dietary intake and reduce nutritional stunting(Reference Vazir, Engle and Balakrishna4).
Yet complementary foods in low-income settings tend to be low in animal foods, fruits and vegetables, and they depend heavily on cultural differences in food choices and different staples that can be grown locally in each region, as Baye et al. in the current issue(Reference Baye, Guyot and Icard-Vernière5) found in Ethiopia. In this case, infant diets tended to be low in Fe, Ca, Zn and vitamins A and C. Fe is particularly problematic and worrying. Poor diet quality, for example a diet based predominantly on cow's milk, might be one of several reasons for the increase in prevalence of Fe deficiency in infants and toddlers in north-west Brazil, suggest Granado et al., also in the current issue(Reference Granado, Augusto and Muniz6).
Besides diet quality, timing is another issue of concern, as diets complementary to breast milk in young children in low-income settings are often introduced too late. For example, in India only 56 % of infants 6–9 months of age receive solid foods with breast milk. They are not fed often enough; less than half of Indian children aged 6–23 months are fed the recommended minimum number of times per day and two-thirds are not fed from the minimum number of food groups. Thus only 21 % of young Indian children are fed according to all three recommended practices(7). Delayed introduction and low quality of complementary feeding of Indian children aged 6–23 months is highlighted in the paper by Malhotra in the current issue(Reference Malhotra8). Malhotra's study, based on data from the latest National Family Health Survey(7), shows that mothers of infants aged 6–8 months who received nutritional advice during antenatal check-ups were more likely to offer their children food more than twice daily than mothers who did not. Furthermore, nutritional information by health professionals tended to improve feeding practices up to 18 months. The need to counsel and educate mothers about children's nutritional needs and appropriate feeding practices is the main message of the paper(Reference Malhotra8). Worth noting is that educational strategies aimed at improving complementary feeding practices work well where populations can afford the needed foods. Otherwise, although education can still have a large impact, providing food supplementation along with education may be necessary to achieve optimal impacts in the short term(Reference Bhutta, Ahmed and Black9). Clearly, further research on actions to promote appropriate complementary feeding is needed in different settings(3).
Not addressed in the articles highlighted in this issue is the problem of overweight, which deserves greater attention in low-income settings. Health appears to deteriorate more rapidly with overweight in populations exposed to nutrient deficits in utero or infancy(Reference Victora, Adair and Fall10). As highlighted in last month's issue of Public Health Nutrition, low- and middle-income countries must now deal simultaneously with the dual problems of diet insufficiencies early in life and excessive weight gain later in life. Strategies to do this are still being tested, but a logical one might, for example, deal with attempts by international food companies to lure their populations into diets based heavily on ultra-processed foods. Overall, low-income countries need to balance short- and long-term approaches in policy making and programme design. And in the current climate of product-based approaches to solve nutrition problems, they should require donors to do the same.
