582205
research-article2015
JHLXXX10.1177/0890334415582205Journal of Human LactationScott et al
Original Research
Timing and Determinants of the Introduction of Complementary Foods in Kuwait: Results of a Prospective Cohort Study
Journal of Human Lactation 2015, Vol. 31(3) 467–473 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415582205 jhl.sagepub.com
Jane A. Scott, PhD, MPH1, Manal Dashti, PhD, MSc2,3, Mona Al-Sughayer, PhD4, and Christine A. Edwards, PhD3
Abstract Background: The early introduction of complementary foods is common in Middle Eastern countries but little is known about the determinants of this practice in this region. Objectives: This prospective cohort study conducted from October 2007 to October 2008 investigated the determinants of the very early (before 17 weeks) introduction of complementary foods in Kuwait and compared rates of this practice against rates reported in the mid-1990s. Methods: A total of 373 women were recruited from maternity hospitals in Kuwait City and followed to 26 weeks postpartum. Data on complementary feeding practices were available from 303 women. Multivariate logistic regression was used to estimate the association of very early introduction of complementary foods with infant sex and maternal characteristics including age, years of education, employment intentions at 6 months postpartum, parity, prepregnancy body mass index, and prepregnancy smoking status. Results: All infants had received complementary foods by 26 weeks of age, with 30.4% receiving complementary foods before 17 weeks of age. Women born in other Arabic countries were less likely to introduce complementary foods before 17 weeks (adjusted odds ratio [adj OR] = 0.40; 95% confidence interval [CI], 0.22-0.73) than women born in Kuwait. Women who were exclusively formula feeding at 6 weeks postpartum were less likely to introduce complementary foods before 17 weeks (adj OR = 0.40; 95% CI, 0.23-0.71) than women who were still breastfeeding. Conclusion: Compared to the mid-1990s, fewer infants in Kuwait were receiving complementary foods before 17 weeks. Nevertheless, all infants had received complementary foods by 6 months of age. Keywords age of introduction, breastfeeding, complementary foods, determinants, indicators, Kuwait, solids
Well Established The early introduction of complementary foods is common in Middle Eastern countries, and in the mid-1990s, 1 in 2 infants in Kuwait reportedly received solids before 4 months.
be exclusively breastfed until 6 months of age and that appropriate complementary foods be introduced thereafter.1 Globally, fewer than 40% of infants younger than 6 months are exclusively breastfed,2 and in the Middle Eastern region, 1
Newly Expressed
School of Public Health, Curtin University, Perth, Australia Nutrition Unit, Jaber Al-Ahmed Armed Forces Hospital, Ministry of Defense, Kuwait City, Kuwait 3 Human Nutrition, School of Medicine, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK 4 Department of Biological Sciences, Faculty of Science, Kuwait University, Kuwait City, Kuwait 2
Less than one third of mothers introduced solids before 17 weeks; however, those who were breastfeeding at 6 weeks were more likely to introduce complementary foods before 17 weeks compared to mothers exclusively formula feeding at 6 weeks.
Date submitted: November 5, 2014; Date accepted: March 25, 2015.
Background The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend that infants
Corresponding Author: Professor Jane A. Scott, PhD, MPH, School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia. Email: [email protected]
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high rates of prelacteal feeding, formula supplementation in the first few months of life, and the early introduction of complementary foods are common.3 In Western countries, the early introduction of complementary foods has been associated with short breastfeeding duration4-8 and maternal smoking,4,5 as well as a variety of nonmodifiable factors including young maternal age,4-8 low maternal education,4,7,8 low socioeconomic status,4,7 and primiparity.6 In comparison, relatively little is known about the determinants of the age of introduction of solids among Middle Eastern women.3 To date, few studies have reported infant feeding practices in Kuwait, and the limited data available are derived from cross-sectional studies that have focused primarily on breastfeeding and bottle-feeding practices.9-13 The most recent Kuwaiti studies to report age of introduction of complementary foods were conducted in the mid-1990s and indicated that 1 in 2 infants had received complementary foods before 4 months of age.10 The objectives of this study conducted from October 2007 to October 2008 were to (1) investigate the age at which women in Kuwait introduce complementary foods to their infants; (2) identify the determinants of the very early introduction of complementary foods; and (3) compare rates of very early introduction of solids in this study against rates reported in the mid-1990s. We have previously reported on the prevalence of breastfeeding and the determinants of breastfeeding initiation14 and duration15 among this cohort of women.
Methods The Kuwait Infant Feeding Survey (KIFS) was a prospective cohort study that recruited from 3 major public hospitals and 1 private hospital located in Kuwait City. All new mothers were visited within 48 hours of delivery and, if eligible, invited to participate in the study by the researcher (M.D.), who provided a written and verbal description of the study. Women were eligible for the study if they were able to read or understand Arabic or English and had delivered a live, healthy, singleton of 36 weeks or more gestational age. Mothers of infants admitted to the special care nursery for minor illnesses or observation were eligible for recruitment. A sample size of 400 would have sufficient power (0.88) with an alpha of .04 to detect a difference in proportions of 15% for any dichotomous sociodemographic or biomedical factor investigated. Therefore, our recruitment target was 500 to allow for a 20% dropout over the 6-month follow-up period. However, for logistical reasons, the time available for recruitment was limited to 6 months, and by the end of this period, we had recruited only 373 mothers with 80 women dropping out of the study at some stage prior to completing the final follow-up interview at 26 weeks. Data were collected using questionnaires previously used in similarly designed studies of Australian women.16,17 The
original English versions of the questionnaires were reviewed by a literacy expert to ensure that they were easy to complete and unambiguous, and they have been shown to have good face and content validity. These questionnaires have been translated subsequently into a variety of languages for use in studies of women in Vietnam,18 China,19,20 the Maldives,21 and Nepal.22 The KIFS versions of the questionnaires were translated into Arabic and pretested on a group of 25 new mothers who were recruited from both public and private maternity hospitals. The mothers were asked to make comments about clarity of wording, ease of completion, and understanding of the questionnaire. A few minor changes were made to the questionnaire based on the comments given (questionnaires are available from the authors on request). Baseline data were collected from participants via a faceto-face interview prior to discharge from hospital. Basic sociodemographic data were collected on request from women who declined to participate to determine if the study cohort was representative of the population of women giving birth at the participating hospitals. Follow-up telephone interviews were conducted at 6, 12, 18, and 26 weeks postpartum. Information on sociodemographic characteristics, maternal lifestyle factors, infant characteristics, biomedical factors, hospital practices, psychosocial factors, and in-hospital feeding practices was collected at baseline. Information on breastfeeding and complementary feeding practices was collected during follow-up interviews. The study was approved by the Medical Faculty Ethics Committee of the University of Glasgow (Application No. FM03906: Approved May 29, 2007) and by the Ministry of Health in Kuwait. Participants provided signed informed consent and were advised that they could refuse to participate or withdraw from the study at any time, without prejudicing their postnatal care or the care of their baby.
Statistical Analysis Although the recommended age of introduction of complementary foods at the time of the survey was 6 months, consistent with the current WHO/UNICEF recommendations,1 the practice of introducing complementary foods at or after 6 months is relatively rare in Middle Eastern countries.3 Therefore, for the purposes of this study analysis, the dependent variable was the very early introduction of solid and semisolid foods, which we defined as before 17 weeks, based on the recommendation of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition’s recommendation that complementary foods should not be introduced before 17 weeks.23 It does not include the time at which foods such as ghee, honey, and/or dates were first offered to infants, as traditionally these may be offered in very small amounts, often from the first days of life.24 Explanatory variables included a variety of maternal and infant characteristics known or suspected to be associated
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Scott et al with the age of introduction of solids.4 These included infant sex, feeding method at 6 weeks postpartum (exclusive formula feeding, partial breastfeeding, predominant breastfeeding), and maternal characteristics including age (< 25, 25-34, ≥ 35 years), years of education (< 12 vs ≥ 12 years), country of birth (Kuwait/Gulf States, other Arabic countries, other countries), parity (primipara vs multipara), employment intentions at 6 months postpartum (working vs not working/ don’t know), prepregnancy body mass index (BMI) (< 25, 25-29.99, ≥ 30 kg/m2), and prepregnancy smoking status (smoker vs nonsmoker). The WHO definition of predominant breastfeeding was used in this study and required infants to receive breast milk as the predominant source of nutrition but allowed the infant to receive water, water-based drinks, fruit juice, ritual fluids, and oral rehydration solutions.25 The chi-square test was used to explore the association between introduction of complementary foods before 17 weeks and individual explanatory factors. All explanatory variables were included in a multivariate logistic regression model to determine which variables were independently predictive of the introduction of complementary foods before 17 weeks of age. A P value of less than .05 was considered significant. Variables found to have a nonsignificant effect on the model were subsequently removed in a backward stepwise fashion (P for removal > .05). All variables remaining in the final model were variables for which, when excluded, the change in deviance compared with the corresponding χ2 test statistic on the relevant degrees of freedom was significant. Results of the logistic regression are presented as the adjusted odds ratio (adj OR) with 95% confidence interval (CI). Statistical analyses were performed using IBM SPSS Statistics, version 22.
Results A total of 439 women were invited to participate in the study and 373 mothers completed the baseline questionnaire while in hospital, giving a response rate of 85%. As previously reported,14,15 there were no significant differences with respect to age, level of education, and feeding method at baseline between participants and those declining to participate (n = 66) or between those women who dropped out of the study prior to completing the final follow-up interview at 26 weeks (n = 80) and those who completed the study. In all, 303 mothers (69% of those invited to participate) had introduced complementary foods to their infants prior to either completing or dropping out of the study, and these women form the analysis population. The characteristics of participants by age of introduction of complementary foods are presented in Table 1. The average and median age of introduction of complementary foods were 20 and 22 weeks, respectively, and all infants had received complementary foods by 26 weeks of age. Slightly less than one third (30.4%) received complementary foods before 17 weeks of age (Figure 1), which is
less than the half of infants reported in earlier studies.10 The very early introduction of complementary foods was independently associated with mother’s country of birth and infant feeding method at 6 weeks of age but was not significantly associated with infant sex, parity, or any other maternal characteristic including age, years of education, employment intentions at 6 months postpartum, prepregnancy BMI, and prepregnancy smoking status. Women who were born in other Arabic countries were significantly less likely to introduce complementary foods before 17 weeks (adj OR = 0.40; 95% CI, 0.22-0.73) than women born in Kuwait (Table 2). Similarly, women who were exclusively formula feeding at 6 weeks postpartum were significantly less likely to introduce complementary foods before 17 weeks than those women who were still breastfeeding (adj OR = 0.40; 95% CI, 0.23-0.71). Mean age of introduction of complementary foods for women who were still breastfeeding at 6 weeks postpartum was 19.9 weeks compared with 20.9 weeks for those who were exclusively formula feeding at 6 weeks, although this difference was not statistically significant (P = .123).
Discussion In this study, all infants had received complementary foods by 26 weeks of age and almost one third before 17 weeks of age. Women who were still breastfeeding at 6 weeks and Kuwaiti-born women were more likely to introduce solids before 17 weeks than women formula feeding at 6 weeks and those from other Arab countries. With the exception of the 1996 Kuwait Family Health Study12 and a smaller cross-sectional study,10 both conducted in the mid-1990s, to our knowledge no other Kuwaiti studies have reported the determinants of the age of introduction of complementary foods. The only contemporaneous study of infant feeding practices found was a cross-sectional study of bottle-feeding practices among women with children younger than 2 years.9 Thus, this study provides the most recent data on the age at which solid foods are introduced to infants in Kuwait. The findings of this study suggest that women in Kuwait are introducing complementary foods later than they did in the mid-1990s. Al-Awadi and Amine,10 in a cross-sectional study of 782 mothers of infants younger than 2 years, reported in 1997 that more than half (51.6%) had introduced complementary foods by 4 months of age, whereas in this study less than one third of women had introduced complementary foods before 17 weeks. This trend toward a later introduction of complementary foods has been reported for other countries.26,27 For instance, in the UK, in 2005, 51% of mothers had introduced complementary foods by 4 months, and this had declined to 30% in 2010.26 Nevertheless, although infant feeding patterns appear to be changing, few children in Kuwait are fed in accordance with the WHO recommendations, since three-quarters of
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Table 1. Association of Maternal and Infant Characteristics with the Introduction of Complementary Foods before 17 Weeks (N = 303). Age of Introduction of Complementary Foods
< 17 Weeks (n = 92)
Characteristic
No.
%
Infant sex Male 48 Female 44 Maternal age, y < 25 21 25-34 55 ≥ 35 16 Maternal years of education < 12 26 ≥ 12 66 Maternal country of birth 59 Kuwait & Gulf Statesb 22 Other Arabic countriesc Other countries 11 Parity Primipara 27 Multipara 65 Maternal employment intentions at 6 months postpartum Working 35 Not working/don’t know 57 Maternal body mass index, kg/m2 < 25 31 34 25.00-29.99 27 ≥ 30 Maternal smoking prepregnancy Smoker 4 Nonsmoker 88 Feeding method at 6 weeks postpartum Predominant or partial breastfeeding 69 Exclusive formula feeding 23
≥ 17 Weeks (n = 211) No.
%
P Valuea
30.2 30.6
111 100
69.8 69.4
.945
31.8 28.5 36.4
45 138 28
68.2 71.5 63.6
.567
37.1 28.3
44 167
62.9 71.7
.160
35.5 22.0 29.7
107 78 26
64.5 78.0 70.3
.067
28.4 31.3
68 143
71.6 68.8
.619
31.0 30.0
78 133
69.0 70.0
.859
24.8 31.2 39.1
94 75 42
75.2 68.8 60.9
.112
26.7 30.6
11 200
73.3 69.4
.749
35.4 21.5
126 84
64.6 78.5
.120
a
Pearson chi-square. The small number of women born in other oil-rich Gulf countries (Saudi Arabia n = 10) was combined with women born in Kuwait due to the similarities in sociodemographic characteristics (eg, age, level of education, partner’s occupation). c Algeria, Egypt, Iraq, Lebanon, Morocco, Palestine, Syria, Yemen. b
Figure 1. Proportion of Infants Receiving Complementary Foods at Each Completed Week of Age. 100
Cumulave Percent
80 60
47.9
40
30.4
20
10.6
0 0
2
4
6
8
10
12
14
16
Infant Age (weeks)
18
20
22
24
26
mothers had introduced complementary foods by the time their baby was 25 weeks old, and all by 26 weeks. A systematic review of infant feeding practices in developed countries4 identified a number of determinants for the early introduction of complementary foods, which included, among other factors, young maternal age and low maternal education. In this study, we found no association with either maternal age or level of education. Earlier Kuwaiti studies conducted in the mid-1990s, however, reported a strong association with maternal education, with illiterate women being more likely to introduce complementary foods later than university educated women.10,12 Al-Awadi and Amine10 reported that 32% of illiterate and 40% of primary school educated women delayed complementary feeding until the
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Scott et al Table 2. Factors Independentlya Associated with the Introduction of Complementary Foods before 17 Weeks. Characteristic Maternal country of birth Kuwait & Gulf Statesb Other Arabic countriesc Other countries Feeding method at 6 weeks Predominant or partial breastfeeding Exclusive formula feeding
Adj OR
95% CI
1.00 0.40 0.64
0.22-0.73 0.29-1.41
1.00 0.40
0.23-0.71
Abbreviations: Adj OR, adjusted odds ratio; CI, confidence interval. a Nonsignificant factors included infant sex, mother’s age, level of education, parity, employment intentions for 6 months postpartum, prepregnancy weight, and smoking status. b The small number of women born in other oil-rich Gulf countries (Saudi Arabia n = 10) was combined with women born in Kuwait due to the similarities in sociodemographic characteristics (eg, age, level of education, partner’s occupation). c Algeria, Egypt, Iraq, Lebanon, Morocco, Palestine, Syria, Yemen.
age of 6 months or more, compared with only 14% of university educated women. Our failure to find an association with education may be due in part to differences in the demographic characteristics of our sample and participants in the earlier study. In our study, 16.6% of mothers had been educated to primary school level, compared to almost a quarter of women in the earlier study who were either illiterate (8.3%) or educated to primary school level (14.6%). Conversely, 34.6% of mothers in our study had a university education compared to 20% of mothers in the earlier study.10 This difference in levels of educational attainment is not necessarily due to selection bias on the part of this study but is likely related to the dramatic economic transition that Kuwait underwent in the second half of the 20th century, following the discovery of vast oil reserves. An economic transition is typically associated with increased investment in education, which inevitably leads to continued increases in educational participation and levels of attainment among women.28 Although Wijndaele et al,4 in their systematic review, reported a lack of consistent evidence for an association with maternal employment, earlier studies of Kuwaiti women12 and other mothers in the region29 showed that the practice of early introduction of complementary foods was more common among mothers who worked. Although we found no independent association with intended employment status in this study, Batal et al29 recently reported that working mothers in Lebanon were 1.78 times more likely to introduce complementary foods before 4 months than mothers who did not work. In this study, women born in other Arabic countries were less likely to introduce complementary foods before 17 weeks than women born in Kuwait, which may reflect the later introduction of complementary foods reported in neighboring countries.4,29-31 In addition, these women were typically the partners of expatriate manual workers from less
affluent Arab countries in the region and hence may have delayed the introduction of complementary foods for economic reasons. Previously, we have reported that this group of women was less likely than Kuwaiti women to discontinue breastfeeding before 26 weeks.15 In developed countries, breastfeeding duration has been directly associated with later introduction of complementary foods.4-8,32,33 Conversely, in this study, women who were breastfeeding at 6 weeks postnatal were more likely to introduce complementary foods before 17 weeks compared with those who were exclusively formula feeding at this age. The belief that breast milk alone is not sufficient to meet the nutritional needs of infants after 3 to 4 months of age has been cited as a common reason for the early introduction of solids by women in a number of countries in this region.3 Although women’s reasons for commencing complementary foods were not investigated in this study, insufficient breast milk was the most common reason given by Turkish mothers31 for beginning complementary foods and by Kuwaiti women for bottle or mixed feeding.10,11 This lack of confidence in milk supply is associated in part with not being able to see how much milk an infant is ingesting. It can be speculated that a woman who is exclusively formula feeding her infant, and able to gauge the amount of formula her infant consumes, may be more confident that her infant is receiving adequate nutrition than a woman who is breastfeeding. It is interesting that we found no difference between women who were either predominantly or partially breastfeeding their infants and so these groups were combined in the final analysis. This suggests that mothers who partially breastfeed are still susceptible to doubting the adequacy of their breast milk supply to meet the nutritional needs of their infant, even when supplementing their milk with infant formula. The limitations of this study are the relatively small sample size recruited and that almost 20% of mothers had dropped out of the study prior to commencing their infants on complementary foods. Failure to detect an association with maternal education identified in other studies, and for which the P value for the chi-square test equaled .160, may therefore be due to a lack of statistical power. However, this is unlikely to have affected our ability to detect an association with the majority of variables of interest as, with the exception of maternal prepregnancy BMI (P = .112), other P values for the chi-square test were large, being greater than .5. Intention to return to work within 6 months of giving birth was used as a proxy for maternal employment at 6 months and, hence, we may have under- or overestimated the actual number of mothers who had returned to work within 6 months of giving birth. In this study, data were collected prospectively, but in earlier studies, data were cross-sectional, making direct comparison of results difficult. Therefore, differences in methodologies may explain, in part, differences in findings between this and earlier studies. The strengths of this study are that, to our knowledge, this is the first prospective longitudinal study of infant feeding practices conducted in Kuwait, it employed
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multivariate analysis, and the age of introduction of complementary foods was measured in weeks.
Conclusion The findings of this study indicate that although, compared to the mid-1990s, fewer infants in Kuwait were receiving complementary foods very early, the majority were nevertheless not being fed in accordance with current recommendations. Although this was seen across all sociodemographic groups, Kuwaiti-born women and those women still breastfeeding at 6 weeks postpartum were more likely to feed their infants complementary foods before 17 weeks of age compared with women from other Arab countries and those exclusively formula feeding at 6 weeks. Acknowledgments The authors sincerely appreciate the assistance given by mothers in their study and the support from the Kuwait Ministry of Health and hospital staff in all participating hospitals.
Author Contributions J.A.S. conceptualized the study, developed the original questionnaires on which the study instruments were based, conducted the final statistical analysis, and wrote the first draft of the manuscript. M.D. participated in the design of the study, collected the data, assisted with statistical analysis, and commented on drafts of the manuscript. C.A.E commented on drafts of the manuscript, and M.A.S. provided assistance with the onsite coordination of the study and commented on drafts of the manuscript. All authors read and approved the final manuscript.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: M.D. was supported by a PhD Scholarship from the Civil Services in Kuwait.
References 1. World Health Organization, UNICEF. Global Strategy for Infant and Young Child Feeding. Geneva, Switzerland: World Health Organization; 2003. 2. World Health Organization Media Centre. Infant and young child feeding. Fact sheet no. 342. http://www.who.int/mediacentre/factsheets/fs342/en/. Accessed April 27, 2014. 3. Nasreddine L, Zeidan MN, Naja F, Hwalla N. Complementary feeding in the MENA region: practices and challenges. Nutr Metab Cardiovasc Dis. 2012;22(10):793-798. 4. Wijndaele K, Lakshman R, Landsbaugh JR, Ong KK, Ogilvie D. Determinants of early weaning and use of unmodified cow’s milk in infants: a systematic review. J Am Diet Assoc. 2009;109(12):2017-2028.
5. Scott J, Binns C, Graham K, Oddy W. Predictors of the early introduction of solid foods in infants: results from a cohort study. BMC Pediatrics. 2009;9:60. 6. Kronborg H, Foverskov E, Vaeth M. Predictors for early introduction of solid food among Danish mothers and infants: an observational study. BMC Pediatrics. 2014;14(1):243. 7. Clayton HB, Li R, Perrine CG, Scanlon KS. Prevalence and reasons for introducing infants early to solid foods: variations by milk feeding type. Pediatrics. 2013;131(4):e1108-e1114. 8. Grummer-Strawn LM, Scanlon KS, Fein SB. Infant feeding and feeding transition during the first year of life. Pediatrics. 2008;122(suppl 2):S36-S42. 9. Al Fadli H, Al-Jasem L, Al-Jady A, Masoud G. Factors underlying bottle-feeding practices in Kuwait. Kuwait Med J. 2006;38(2):118-121. 10. Al-Awadi F, Amine E. Recent trends in infant feeding patterns and weaning practices in Kuwait. East Mediterr Health J. 1997;3(3):501-510. 11. Amine EK, Al-Awadi F, Rabie M. Infant feeding pattern and weaning practices in Kuwait. J R Soc Health. 1989;109(5): 178-180. 12. Alnesef Y, Al-Rashoud R, Farid S. Kuwait Family Health Survey 1996, Preliminary Report. Kuwait: Ministry of Health; 1996. 13. Al Bustan M, Kohli BR. Socio-economic and demographic factors influencing breast-feeding among Kuwaiti women. Genus. 1988;44(1-2):265-278. 14. Dashti M, Scott JA, Edwards CA, Al-Sughayer M. Determinants of breastfeeding initiation among mothers in Kuwait. Int Breastfeed J. 2010;5:7. 15. Dashti M, Scott J, Edwards C, Al-Sughayer M. Predictors of breastfeeding duration among women in Kuwait: results of a prospective cohort study. Nutrients. 2014;6(2):711-728. 16. Scott J, Aitkin I, Binns C, Aroni R. Factors associated with the duration of breast-feeding amongst women in Perth, Australia. Acta Paediatr. 1999;88(4):416-421. 17. Scott JA, Binns CW, Oddy WH, Graham KI. Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics. 2006;17(4):e646-e655. 18. Duong DV, Binns CW, Lee AH. Introduction of complementary foods to infants within the first six months postpartum in rural Vietnam. Acta Paediatr. 2005;94(12):1714-1720. 19. Liu P, Qiao L, Xu F, Zhang M, Wang Y, Binns CW. Factors associated with breastfeeding duration: a 30-month cohort study in northwest China. J Hum Lact. 2013;29(2):253-259. 20. Tang L, Lee AH, Binns CW. Factors associated with breastfeeding duration: a prospective cohort study in Sichuan Province, China [published online Novemebr 20, 2014]. World J Pediatrics. doi:10.1007/s12519-014-0520-y. 21. Abdulraheem R, Binns CW. The infant feeding practices of mothers in the Maldives. Public Health Nutr. 2007;10(5): 502-507. 22. Karkee R, Lee AH, Khanal V, Binns CW. A community-based prospective cohort study of exclusive breastfeeding in central Nepal. BMC Public Health. 2014;14:927. 23. Agostini C, Decsi T, Fewtrell M, et al. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2008;46(1):99-110. 24. Musaiger AO. Breastfeeding patterns in the Arabian Gulf countries. World Rev Nutr Diet. 1995;78:164-190.
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Scott et al 25. World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices: Conclusions of a Consensus Meeting Held 6–8 November 2007 in Washington D.C., USA. Geneva, Switzerland: World Health Organization; 2008. 26. McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew M. Infant Feeding Survey 2010. Leeds, UK: Health and Social Care Information Centre; 2012. 27. Scott J, Pollard C, Trevithick R. What impact do changes to infant feeding recommendations have on infant feeding practices? Analysis of data from the WA Health and Wellbeing Surveillance System. Paper presented at: 17th International Society for Research in Human Milk and Lactation; October 23-27, 2014; Kiawah Island, South Carolina. 28. Bloom D, Canning D, Sevilla J. Economic Growth and the Demographic Transition. NBER Working Paper No. 8685. Cambridge, MA: National Bureau of Economic Research; 2001.
29. Batal M, Boulghourjian C, Akik C. Complementary feeding patterns in a developing country: a cross-sectional study across Lebanon. East Mediterr Health J. 2010;16(2):180-186. 30. Koosha A, Hashemifesharaki R, Mousavinasab N. Breast feeding patterns and factors determining exclusive breastfeeding. Singapore Med J. 2008;49(12):1002-1006. 31. Erkul PE, Yalcin SS, Kilic S. Evaluation of breastfeeding in a Baby-Friendly city, Corum, Turkey. Cent Eur J Public Health. 2010;18(1):31-37. 32. Giovannini M, Banderali G, Radaelli G, Carmine V, Riva E, Agostoni C. Monitoring breastfeeding rates in Italy: national surveys 1995 and 1999. Acta Paediatr. 2003;92(3): 357-363. 33. Hendricks K, Briefel R, Novak T, Ziegler P. Maternal and child characteristics associated with infant and toddler feeding practices. J Am Diet Assoc. 2006;106(suppl 1):S135-S148.
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research-article2015
JHLXXX10.1177/0890334415582205Journal of Human LactationScott et al
Original Research
Timing and Determinants of the Introduction of Complementary Foods in Kuwait: Results of a Prospective Cohort Study
Journal of Human Lactation 2015, Vol. 31(3) 467–473 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415582205 jhl.sagepub.com
Jane A. Scott, PhD, MPH1, Manal Dashti, PhD, MSc2,3, Mona Al-Sughayer, PhD4, and Christine A. Edwards, PhD3
Abstract Background: The early introduction of complementary foods is common in Middle Eastern countries but little is known about the determinants of this practice in this region. Objectives: This prospective cohort study conducted from October 2007 to October 2008 investigated the determinants of the very early (before 17 weeks) introduction of complementary foods in Kuwait and compared rates of this practice against rates reported in the mid-1990s. Methods: A total of 373 women were recruited from maternity hospitals in Kuwait City and followed to 26 weeks postpartum. Data on complementary feeding practices were available from 303 women. Multivariate logistic regression was used to estimate the association of very early introduction of complementary foods with infant sex and maternal characteristics including age, years of education, employment intentions at 6 months postpartum, parity, prepregnancy body mass index, and prepregnancy smoking status. Results: All infants had received complementary foods by 26 weeks of age, with 30.4% receiving complementary foods before 17 weeks of age. Women born in other Arabic countries were less likely to introduce complementary foods before 17 weeks (adjusted odds ratio [adj OR] = 0.40; 95% confidence interval [CI], 0.22-0.73) than women born in Kuwait. Women who were exclusively formula feeding at 6 weeks postpartum were less likely to introduce complementary foods before 17 weeks (adj OR = 0.40; 95% CI, 0.23-0.71) than women who were still breastfeeding. Conclusion: Compared to the mid-1990s, fewer infants in Kuwait were receiving complementary foods before 17 weeks. Nevertheless, all infants had received complementary foods by 6 months of age. Keywords age of introduction, breastfeeding, complementary foods, determinants, indicators, Kuwait, solids
Well Established The early introduction of complementary foods is common in Middle Eastern countries, and in the mid-1990s, 1 in 2 infants in Kuwait reportedly received solids before 4 months.
be exclusively breastfed until 6 months of age and that appropriate complementary foods be introduced thereafter.1 Globally, fewer than 40% of infants younger than 6 months are exclusively breastfed,2 and in the Middle Eastern region, 1
Newly Expressed
School of Public Health, Curtin University, Perth, Australia Nutrition Unit, Jaber Al-Ahmed Armed Forces Hospital, Ministry of Defense, Kuwait City, Kuwait 3 Human Nutrition, School of Medicine, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK 4 Department of Biological Sciences, Faculty of Science, Kuwait University, Kuwait City, Kuwait 2
Less than one third of mothers introduced solids before 17 weeks; however, those who were breastfeeding at 6 weeks were more likely to introduce complementary foods before 17 weeks compared to mothers exclusively formula feeding at 6 weeks.
Date submitted: November 5, 2014; Date accepted: March 25, 2015.
Background The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend that infants
Corresponding Author: Professor Jane A. Scott, PhD, MPH, School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia. Email: [email protected]
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high rates of prelacteal feeding, formula supplementation in the first few months of life, and the early introduction of complementary foods are common.3 In Western countries, the early introduction of complementary foods has been associated with short breastfeeding duration4-8 and maternal smoking,4,5 as well as a variety of nonmodifiable factors including young maternal age,4-8 low maternal education,4,7,8 low socioeconomic status,4,7 and primiparity.6 In comparison, relatively little is known about the determinants of the age of introduction of solids among Middle Eastern women.3 To date, few studies have reported infant feeding practices in Kuwait, and the limited data available are derived from cross-sectional studies that have focused primarily on breastfeeding and bottle-feeding practices.9-13 The most recent Kuwaiti studies to report age of introduction of complementary foods were conducted in the mid-1990s and indicated that 1 in 2 infants had received complementary foods before 4 months of age.10 The objectives of this study conducted from October 2007 to October 2008 were to (1) investigate the age at which women in Kuwait introduce complementary foods to their infants; (2) identify the determinants of the very early introduction of complementary foods; and (3) compare rates of very early introduction of solids in this study against rates reported in the mid-1990s. We have previously reported on the prevalence of breastfeeding and the determinants of breastfeeding initiation14 and duration15 among this cohort of women.
Methods The Kuwait Infant Feeding Survey (KIFS) was a prospective cohort study that recruited from 3 major public hospitals and 1 private hospital located in Kuwait City. All new mothers were visited within 48 hours of delivery and, if eligible, invited to participate in the study by the researcher (M.D.), who provided a written and verbal description of the study. Women were eligible for the study if they were able to read or understand Arabic or English and had delivered a live, healthy, singleton of 36 weeks or more gestational age. Mothers of infants admitted to the special care nursery for minor illnesses or observation were eligible for recruitment. A sample size of 400 would have sufficient power (0.88) with an alpha of .04 to detect a difference in proportions of 15% for any dichotomous sociodemographic or biomedical factor investigated. Therefore, our recruitment target was 500 to allow for a 20% dropout over the 6-month follow-up period. However, for logistical reasons, the time available for recruitment was limited to 6 months, and by the end of this period, we had recruited only 373 mothers with 80 women dropping out of the study at some stage prior to completing the final follow-up interview at 26 weeks. Data were collected using questionnaires previously used in similarly designed studies of Australian women.16,17 The
original English versions of the questionnaires were reviewed by a literacy expert to ensure that they were easy to complete and unambiguous, and they have been shown to have good face and content validity. These questionnaires have been translated subsequently into a variety of languages for use in studies of women in Vietnam,18 China,19,20 the Maldives,21 and Nepal.22 The KIFS versions of the questionnaires were translated into Arabic and pretested on a group of 25 new mothers who were recruited from both public and private maternity hospitals. The mothers were asked to make comments about clarity of wording, ease of completion, and understanding of the questionnaire. A few minor changes were made to the questionnaire based on the comments given (questionnaires are available from the authors on request). Baseline data were collected from participants via a faceto-face interview prior to discharge from hospital. Basic sociodemographic data were collected on request from women who declined to participate to determine if the study cohort was representative of the population of women giving birth at the participating hospitals. Follow-up telephone interviews were conducted at 6, 12, 18, and 26 weeks postpartum. Information on sociodemographic characteristics, maternal lifestyle factors, infant characteristics, biomedical factors, hospital practices, psychosocial factors, and in-hospital feeding practices was collected at baseline. Information on breastfeeding and complementary feeding practices was collected during follow-up interviews. The study was approved by the Medical Faculty Ethics Committee of the University of Glasgow (Application No. FM03906: Approved May 29, 2007) and by the Ministry of Health in Kuwait. Participants provided signed informed consent and were advised that they could refuse to participate or withdraw from the study at any time, without prejudicing their postnatal care or the care of their baby.
Statistical Analysis Although the recommended age of introduction of complementary foods at the time of the survey was 6 months, consistent with the current WHO/UNICEF recommendations,1 the practice of introducing complementary foods at or after 6 months is relatively rare in Middle Eastern countries.3 Therefore, for the purposes of this study analysis, the dependent variable was the very early introduction of solid and semisolid foods, which we defined as before 17 weeks, based on the recommendation of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition’s recommendation that complementary foods should not be introduced before 17 weeks.23 It does not include the time at which foods such as ghee, honey, and/or dates were first offered to infants, as traditionally these may be offered in very small amounts, often from the first days of life.24 Explanatory variables included a variety of maternal and infant characteristics known or suspected to be associated
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Scott et al with the age of introduction of solids.4 These included infant sex, feeding method at 6 weeks postpartum (exclusive formula feeding, partial breastfeeding, predominant breastfeeding), and maternal characteristics including age (< 25, 25-34, ≥ 35 years), years of education (< 12 vs ≥ 12 years), country of birth (Kuwait/Gulf States, other Arabic countries, other countries), parity (primipara vs multipara), employment intentions at 6 months postpartum (working vs not working/ don’t know), prepregnancy body mass index (BMI) (< 25, 25-29.99, ≥ 30 kg/m2), and prepregnancy smoking status (smoker vs nonsmoker). The WHO definition of predominant breastfeeding was used in this study and required infants to receive breast milk as the predominant source of nutrition but allowed the infant to receive water, water-based drinks, fruit juice, ritual fluids, and oral rehydration solutions.25 The chi-square test was used to explore the association between introduction of complementary foods before 17 weeks and individual explanatory factors. All explanatory variables were included in a multivariate logistic regression model to determine which variables were independently predictive of the introduction of complementary foods before 17 weeks of age. A P value of less than .05 was considered significant. Variables found to have a nonsignificant effect on the model were subsequently removed in a backward stepwise fashion (P for removal > .05). All variables remaining in the final model were variables for which, when excluded, the change in deviance compared with the corresponding χ2 test statistic on the relevant degrees of freedom was significant. Results of the logistic regression are presented as the adjusted odds ratio (adj OR) with 95% confidence interval (CI). Statistical analyses were performed using IBM SPSS Statistics, version 22.
Results A total of 439 women were invited to participate in the study and 373 mothers completed the baseline questionnaire while in hospital, giving a response rate of 85%. As previously reported,14,15 there were no significant differences with respect to age, level of education, and feeding method at baseline between participants and those declining to participate (n = 66) or between those women who dropped out of the study prior to completing the final follow-up interview at 26 weeks (n = 80) and those who completed the study. In all, 303 mothers (69% of those invited to participate) had introduced complementary foods to their infants prior to either completing or dropping out of the study, and these women form the analysis population. The characteristics of participants by age of introduction of complementary foods are presented in Table 1. The average and median age of introduction of complementary foods were 20 and 22 weeks, respectively, and all infants had received complementary foods by 26 weeks of age. Slightly less than one third (30.4%) received complementary foods before 17 weeks of age (Figure 1), which is
less than the half of infants reported in earlier studies.10 The very early introduction of complementary foods was independently associated with mother’s country of birth and infant feeding method at 6 weeks of age but was not significantly associated with infant sex, parity, or any other maternal characteristic including age, years of education, employment intentions at 6 months postpartum, prepregnancy BMI, and prepregnancy smoking status. Women who were born in other Arabic countries were significantly less likely to introduce complementary foods before 17 weeks (adj OR = 0.40; 95% CI, 0.22-0.73) than women born in Kuwait (Table 2). Similarly, women who were exclusively formula feeding at 6 weeks postpartum were significantly less likely to introduce complementary foods before 17 weeks than those women who were still breastfeeding (adj OR = 0.40; 95% CI, 0.23-0.71). Mean age of introduction of complementary foods for women who were still breastfeeding at 6 weeks postpartum was 19.9 weeks compared with 20.9 weeks for those who were exclusively formula feeding at 6 weeks, although this difference was not statistically significant (P = .123).
Discussion In this study, all infants had received complementary foods by 26 weeks of age and almost one third before 17 weeks of age. Women who were still breastfeeding at 6 weeks and Kuwaiti-born women were more likely to introduce solids before 17 weeks than women formula feeding at 6 weeks and those from other Arab countries. With the exception of the 1996 Kuwait Family Health Study12 and a smaller cross-sectional study,10 both conducted in the mid-1990s, to our knowledge no other Kuwaiti studies have reported the determinants of the age of introduction of complementary foods. The only contemporaneous study of infant feeding practices found was a cross-sectional study of bottle-feeding practices among women with children younger than 2 years.9 Thus, this study provides the most recent data on the age at which solid foods are introduced to infants in Kuwait. The findings of this study suggest that women in Kuwait are introducing complementary foods later than they did in the mid-1990s. Al-Awadi and Amine,10 in a cross-sectional study of 782 mothers of infants younger than 2 years, reported in 1997 that more than half (51.6%) had introduced complementary foods by 4 months of age, whereas in this study less than one third of women had introduced complementary foods before 17 weeks. This trend toward a later introduction of complementary foods has been reported for other countries.26,27 For instance, in the UK, in 2005, 51% of mothers had introduced complementary foods by 4 months, and this had declined to 30% in 2010.26 Nevertheless, although infant feeding patterns appear to be changing, few children in Kuwait are fed in accordance with the WHO recommendations, since three-quarters of
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Table 1. Association of Maternal and Infant Characteristics with the Introduction of Complementary Foods before 17 Weeks (N = 303). Age of Introduction of Complementary Foods
< 17 Weeks (n = 92)
Characteristic
No.
%
Infant sex Male 48 Female 44 Maternal age, y < 25 21 25-34 55 ≥ 35 16 Maternal years of education < 12 26 ≥ 12 66 Maternal country of birth 59 Kuwait & Gulf Statesb 22 Other Arabic countriesc Other countries 11 Parity Primipara 27 Multipara 65 Maternal employment intentions at 6 months postpartum Working 35 Not working/don’t know 57 Maternal body mass index, kg/m2 < 25 31 34 25.00-29.99 27 ≥ 30 Maternal smoking prepregnancy Smoker 4 Nonsmoker 88 Feeding method at 6 weeks postpartum Predominant or partial breastfeeding 69 Exclusive formula feeding 23
≥ 17 Weeks (n = 211) No.
%
P Valuea
30.2 30.6
111 100
69.8 69.4
.945
31.8 28.5 36.4
45 138 28
68.2 71.5 63.6
.567
37.1 28.3
44 167
62.9 71.7
.160
35.5 22.0 29.7
107 78 26
64.5 78.0 70.3
.067
28.4 31.3
68 143
71.6 68.8
.619
31.0 30.0
78 133
69.0 70.0
.859
24.8 31.2 39.1
94 75 42
75.2 68.8 60.9
.112
26.7 30.6
11 200
73.3 69.4
.749
35.4 21.5
126 84
64.6 78.5
.120
a
Pearson chi-square. The small number of women born in other oil-rich Gulf countries (Saudi Arabia n = 10) was combined with women born in Kuwait due to the similarities in sociodemographic characteristics (eg, age, level of education, partner’s occupation). c Algeria, Egypt, Iraq, Lebanon, Morocco, Palestine, Syria, Yemen. b
Figure 1. Proportion of Infants Receiving Complementary Foods at Each Completed Week of Age. 100
Cumulave Percent
80 60
47.9
40
30.4
20
10.6
0 0
2
4
6
8
10
12
14
16
Infant Age (weeks)
18
20
22
24
26
mothers had introduced complementary foods by the time their baby was 25 weeks old, and all by 26 weeks. A systematic review of infant feeding practices in developed countries4 identified a number of determinants for the early introduction of complementary foods, which included, among other factors, young maternal age and low maternal education. In this study, we found no association with either maternal age or level of education. Earlier Kuwaiti studies conducted in the mid-1990s, however, reported a strong association with maternal education, with illiterate women being more likely to introduce complementary foods later than university educated women.10,12 Al-Awadi and Amine10 reported that 32% of illiterate and 40% of primary school educated women delayed complementary feeding until the
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Scott et al Table 2. Factors Independentlya Associated with the Introduction of Complementary Foods before 17 Weeks. Characteristic Maternal country of birth Kuwait & Gulf Statesb Other Arabic countriesc Other countries Feeding method at 6 weeks Predominant or partial breastfeeding Exclusive formula feeding
Adj OR
95% CI
1.00 0.40 0.64
0.22-0.73 0.29-1.41
1.00 0.40
0.23-0.71
Abbreviations: Adj OR, adjusted odds ratio; CI, confidence interval. a Nonsignificant factors included infant sex, mother’s age, level of education, parity, employment intentions for 6 months postpartum, prepregnancy weight, and smoking status. b The small number of women born in other oil-rich Gulf countries (Saudi Arabia n = 10) was combined with women born in Kuwait due to the similarities in sociodemographic characteristics (eg, age, level of education, partner’s occupation). c Algeria, Egypt, Iraq, Lebanon, Morocco, Palestine, Syria, Yemen.
age of 6 months or more, compared with only 14% of university educated women. Our failure to find an association with education may be due in part to differences in the demographic characteristics of our sample and participants in the earlier study. In our study, 16.6% of mothers had been educated to primary school level, compared to almost a quarter of women in the earlier study who were either illiterate (8.3%) or educated to primary school level (14.6%). Conversely, 34.6% of mothers in our study had a university education compared to 20% of mothers in the earlier study.10 This difference in levels of educational attainment is not necessarily due to selection bias on the part of this study but is likely related to the dramatic economic transition that Kuwait underwent in the second half of the 20th century, following the discovery of vast oil reserves. An economic transition is typically associated with increased investment in education, which inevitably leads to continued increases in educational participation and levels of attainment among women.28 Although Wijndaele et al,4 in their systematic review, reported a lack of consistent evidence for an association with maternal employment, earlier studies of Kuwaiti women12 and other mothers in the region29 showed that the practice of early introduction of complementary foods was more common among mothers who worked. Although we found no independent association with intended employment status in this study, Batal et al29 recently reported that working mothers in Lebanon were 1.78 times more likely to introduce complementary foods before 4 months than mothers who did not work. In this study, women born in other Arabic countries were less likely to introduce complementary foods before 17 weeks than women born in Kuwait, which may reflect the later introduction of complementary foods reported in neighboring countries.4,29-31 In addition, these women were typically the partners of expatriate manual workers from less
affluent Arab countries in the region and hence may have delayed the introduction of complementary foods for economic reasons. Previously, we have reported that this group of women was less likely than Kuwaiti women to discontinue breastfeeding before 26 weeks.15 In developed countries, breastfeeding duration has been directly associated with later introduction of complementary foods.4-8,32,33 Conversely, in this study, women who were breastfeeding at 6 weeks postnatal were more likely to introduce complementary foods before 17 weeks compared with those who were exclusively formula feeding at this age. The belief that breast milk alone is not sufficient to meet the nutritional needs of infants after 3 to 4 months of age has been cited as a common reason for the early introduction of solids by women in a number of countries in this region.3 Although women’s reasons for commencing complementary foods were not investigated in this study, insufficient breast milk was the most common reason given by Turkish mothers31 for beginning complementary foods and by Kuwaiti women for bottle or mixed feeding.10,11 This lack of confidence in milk supply is associated in part with not being able to see how much milk an infant is ingesting. It can be speculated that a woman who is exclusively formula feeding her infant, and able to gauge the amount of formula her infant consumes, may be more confident that her infant is receiving adequate nutrition than a woman who is breastfeeding. It is interesting that we found no difference between women who were either predominantly or partially breastfeeding their infants and so these groups were combined in the final analysis. This suggests that mothers who partially breastfeed are still susceptible to doubting the adequacy of their breast milk supply to meet the nutritional needs of their infant, even when supplementing their milk with infant formula. The limitations of this study are the relatively small sample size recruited and that almost 20% of mothers had dropped out of the study prior to commencing their infants on complementary foods. Failure to detect an association with maternal education identified in other studies, and for which the P value for the chi-square test equaled .160, may therefore be due to a lack of statistical power. However, this is unlikely to have affected our ability to detect an association with the majority of variables of interest as, with the exception of maternal prepregnancy BMI (P = .112), other P values for the chi-square test were large, being greater than .5. Intention to return to work within 6 months of giving birth was used as a proxy for maternal employment at 6 months and, hence, we may have under- or overestimated the actual number of mothers who had returned to work within 6 months of giving birth. In this study, data were collected prospectively, but in earlier studies, data were cross-sectional, making direct comparison of results difficult. Therefore, differences in methodologies may explain, in part, differences in findings between this and earlier studies. The strengths of this study are that, to our knowledge, this is the first prospective longitudinal study of infant feeding practices conducted in Kuwait, it employed
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multivariate analysis, and the age of introduction of complementary foods was measured in weeks.
Conclusion The findings of this study indicate that although, compared to the mid-1990s, fewer infants in Kuwait were receiving complementary foods very early, the majority were nevertheless not being fed in accordance with current recommendations. Although this was seen across all sociodemographic groups, Kuwaiti-born women and those women still breastfeeding at 6 weeks postpartum were more likely to feed their infants complementary foods before 17 weeks of age compared with women from other Arab countries and those exclusively formula feeding at 6 weeks. Acknowledgments The authors sincerely appreciate the assistance given by mothers in their study and the support from the Kuwait Ministry of Health and hospital staff in all participating hospitals.
Author Contributions J.A.S. conceptualized the study, developed the original questionnaires on which the study instruments were based, conducted the final statistical analysis, and wrote the first draft of the manuscript. M.D. participated in the design of the study, collected the data, assisted with statistical analysis, and commented on drafts of the manuscript. C.A.E commented on drafts of the manuscript, and M.A.S. provided assistance with the onsite coordination of the study and commented on drafts of the manuscript. All authors read and approved the final manuscript.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: M.D. was supported by a PhD Scholarship from the Civil Services in Kuwait.
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Scott et al 25. World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices: Conclusions of a Consensus Meeting Held 6–8 November 2007 in Washington D.C., USA. Geneva, Switzerland: World Health Organization; 2008. 26. McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew M. Infant Feeding Survey 2010. Leeds, UK: Health and Social Care Information Centre; 2012. 27. Scott J, Pollard C, Trevithick R. What impact do changes to infant feeding recommendations have on infant feeding practices? Analysis of data from the WA Health and Wellbeing Surveillance System. Paper presented at: 17th International Society for Research in Human Milk and Lactation; October 23-27, 2014; Kiawah Island, South Carolina. 28. Bloom D, Canning D, Sevilla J. Economic Growth and the Demographic Transition. NBER Working Paper No. 8685. Cambridge, MA: National Bureau of Economic Research; 2001.
29. Batal M, Boulghourjian C, Akik C. Complementary feeding patterns in a developing country: a cross-sectional study across Lebanon. East Mediterr Health J. 2010;16(2):180-186. 30. Koosha A, Hashemifesharaki R, Mousavinasab N. Breast feeding patterns and factors determining exclusive breastfeeding. Singapore Med J. 2008;49(12):1002-1006. 31. Erkul PE, Yalcin SS, Kilic S. Evaluation of breastfeeding in a Baby-Friendly city, Corum, Turkey. Cent Eur J Public Health. 2010;18(1):31-37. 32. Giovannini M, Banderali G, Radaelli G, Carmine V, Riva E, Agostoni C. Monitoring breastfeeding rates in Italy: national surveys 1995 and 1999. Acta Paediatr. 2003;92(3): 357-363. 33. Hendricks K, Briefel R, Novak T, Ziegler P. Maternal and child characteristics associated with infant and toddler feeding practices. J Am Diet Assoc. 2006;106(suppl 1):S135-S148.
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