Knowledge and attitude on complementary feeding practices among parents or main care givers of children aged less than sixmonths admitted to Paediatric wards at TH/Jaffna

The objective of the study was to determine the knowledge, attitude and practices of mothers or primary care givers regarding complementary feeding. An Institutional based descriptive study conducted in all three paediatric wards of Teaching Hospital Jaffna over a period of one year. A pretested questionnaire was administered to ascertain their knowledge, attitude and practices regarding complementary feeding. Various believes affecting their practices, knowledge on hygienic practices and feeding during illnesses was also assessed.

The objective of the study was to determine the knowledge, attitude and practices of mothers or primary care givers regarding complementary feeding. An Institutional based descriptive study conducted in all three paediatric wards of Teaching Hospital Jaffna over a period of one year. A pretested questionnaire was administered to ascertain their knowledge, attitude and practices regarding complementary feeding. Various believes affecting their practices, knowledge on hygienic practices and feeding during illnesses was also assessed.
A total of 302 mothers and primary care givers of children aged upto six months admitted to paediatric wards were recruited and 51.3% (n=155) were aware that complementary feeding (CF) had to be introduced at the end of six months. A total of 66 (21.9%) mothers had already started CF but only half of them (10.3%) followed a medical advice. Poor milk flow was the main reason for early CF without medical advice. Around 90% were aware of good hygienic practices while feeding the child. Mothers who strongly agreed to give extra meal for 2weeks when the child recovered from acute illness and continued it for six months from the child started to gain weight when there was growth faltering were 1.7%(n=5) and 3.3%(n=10) respectively. Nearly 37 (12.3%) mothers strongly agreed that the child's nutritional needs increased during the illness whereas 54% (n=163) strongly disagreed. Overall 22.8% (n=69) had good knowledge, 74.2% had average knowledge and 3% had poor knowledge about CF. Literacy level, economic status, type of family, marital status of the mother and the ability to read and understand the facts given in CHDR were significantly related (p<0.05) with the knowledge of mothers regarding complementary feeding.

Introduction
Growth is an important part of life of a child. The process of growth begins from the moment of conception and continues till the child becomes a fully matured adult. Nutrients are essential for maintaining growth of infants. (1) During first six months of life breast milk should be fed alone and must remain the first food for infants. After six months of age breast feeding is not sufficient for providing the nutrients needed for a growing child.
The complementary feeding is the slow diminution in breast feeding, with initiation of foods other than breast milk into an infant's dietary regime. (2) Complementary foods (CF) initiated from the start of the seventh month while continuing to breast feed for a period of 2 years or more. (3) At the same early CF may lead to calorie and nutritional deficiency. (2) There are pros and cons with the early and late complementary feeding practices. There is a higher risk of gastrointestinal infections that endure principal rationalization against the initiation of complementary foods early. (3) Complementary foods are usually introduced late in developing countries and could lead to unfavorable outcomes on nutrition, growth and development of the child as well as difficulties in consuming family diet at one year. (4,5) Absorption of iron in breast milk is unpredictable with early introduction of cereals and particularly vegetables, whereas iron deficiency anemia is also noted when weaning is started late. (6) There is some evidence that this may safeguard against the occurrence of allergic disease. (7) Malnutrition is more common during the transitional period from six months rather than in the first 4 to 6 months of life. It is beneficial to introduce complementary foods to fill the nutritional gap between the entire energy need and the energy provided by breast milk i.e., when a baby grows and become more active around 6 months of age. (8) Commercial weaning foods will not reduce the incidence of malnutrition in the developing countries as poor families with the highest rates of malnutrition, may not be able to afford these foods. (4) Individuals' exposure to flavours confers to their distinctive pattern of taste preferences in selecting foods. Taste perception starts to develop in utero, and the senses of taste and smell continue to develop after birth. Early exposure to flavours, first in utero via amniotic fluid and later through breast milk impact on later food preferences. (9) Infants accept cereal prepared with breast milk or it flavored likes fruits, if mothers consumed these foods during pregnancy and breast feeding. (10) For a growing baby feeding time is the period of learning. So the child should be fed patiently and an interactive way to encourage feeding. Forceful feeding is never accepted. (4) It is an unpleasant experience to the child, and could lead to Food Phobia. (11) An extra diet has to be given when the child is ill and has to be continued for 2 weeks when they are recovering from the illness. If they have growth faltering due to ill health, the extra diet has to be continued for at least 2weeks after their weight returns to the original growth potential of them. (4) Maternal literacy has been identified as a key factor in improving child nutrition. (12) Reading CHDR was facilitated by high-level of maternal education. The information can be conveyed in specific, short, simple, and attractive way using different codes of colour according to chapters to increase the reader friendliness and to facilitate reading by less educated mothers. (13) Under nutrition is a major problem among preschool children in Sri Lanka. Quality and quantity of the complementary feeding has been highlighted as the main contributory factor for this nutritional problem. (12,14) Methods This Institutional based descriptive cross sectional study was carried out among all primary care givers of children aged less than six months admitted to paediatric wards at Teaching Hospital, Jaffna (THJ). The study period was from April 2017 to July 2018. A random sampling technique was used to collect the data. Sample was calculated on the basis of 77.7% prevalence of knowledge on complementary feeding in Karachi-Pakistan according to a study conducted among Female Health providers working in a Tertiary Care and at 95% confidence interval with 0.05 margin of error, non-response rate as 10%. The estimated sample was 300. (18) A pretested structured questionnaire was administered by the interviewer to collect the data.
Data on demographic factors, consistency and type of complementary foods, feeding during acute illness, hygienic practices and complementary feeding practices were collected. Informed written consent was taken after briefing participants about the aim of study.
Based on the data collected a scoring system was used to assess overall knowledge. The total score was 100 and a score of ≥60 was considered as good knowledge, 59-40 as average knowledge and ≤39 as poor knowledge.
Statistically significant correlation was checked with the literacy level, family income, type of the family, marital status and the ability to understand the facts given in CHDR. Data was coded and entered into SPSS version 21 and analyzed with Chi-Square Tests. A p value of <0.05 was considered as statistically significant correlation. Ethical approval was obtained from the ethical review committee of the Sri Lanka College of Paediatricians.

Demographic factors
Total 302 primary care givers from all three paediatric wards of THJ participated in the study. Mean age of children who were included in the study was 3.69+ 1.63 months and majority 146 (48.3%) were hospitalized due to respiratory symptoms. Socio demographic details are given in Table 1.

Complementary feeding practices during illness
Five sentences were given regarding the facts of feeding during acute illness and were asked to respond as whether they agreed, disagreed or not sure about the fact. Details of responses given in table 3. All the given responses were correct. Only one response was agreed by nearly half of the samples (45.6%); whereas remaining four responses agreed by less than 20% of population. Upon the statistical test there was a statistically significant correlation between the facts regarding the feeding practices during acute illness and literacy level (p-0.007), total income (p-0.000) & understanding the facts given in CHDR (p-0.000).

Hygienic practices during complementary feeding
Four correct responses and an incorrect response were given to assess the knowledge and ask to respond as right or wrong. All the right facts were accepted as right by most of them and the incorrect fact was responded as wrong by 83% of samples. Hygienic practices during complementary feeding were statistically not significantly correlated with literacy level, family income, type of family, marital status and the ability to understand the facts given in CHDR Given responses and the hygienic practices are given in table 5

Overall knowledge
When consider all the data together 69 (22.8%) caretakers had good knowledge, 224 (74.2%) had average knowledge and 9 (3%) had poor knowledge. There was a statistically significant correlation between the overall knowledge and the ability to understand the facts given in CHDR. Economic status, Literacy level, marital status and type of family were statistically not significantly correlated with the overall knowledge.

Discussion
Complementary feeding practices depend on various factors such as socioeconomical status, educational level of the care taker, cultural practices, geographic area (rural/urban) etc. (2,4,8) In Awareness needs to be generated through Information Education Communication (IEC) activities at hospitals and primary care level regarding the benefits and importance of timely complementary feeding. The limitations of our study is that it was conducted in a tertiary care hospital among the children who admitted at paediatric wards. Community based study may be more reliable for better evaluation of demographic variables.

Conclusion
Literacy level, economic status & the ability to understand facts given in CHDR had significantly influence the knowledge on complementary feeding related to time of initiation, consistency and type of complementary food, and the feeding during acute illness.