Journal Pone 0250562

PLOS ONE
RESEARCH ARTICLE
Effect of inappropriate complementary

feeding practices on the nutritional status of
children aged 6-24 months in urban Moshi,
Northern Tanzania: Cohort study
Rachel Masuke ID1*, Sia E. Msuya1,2,3, Johnson M. Mahande1, Ester J. Diarz1, Babill Stray-
Pedersen4,5, Ola Jahanpour1,6, Melina Mgongo2,4
1 Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical
University College, Moshi, Tanzania, 2 Department of Community Health, Institute of Public Health,
Kilimanjaro Christian Medical University College, Moshi, Tanzania, 3 Department of Community Medicine,
a1111111111 Kilimanjaro Christian Medical Centre, Moshi, Tanzania, 4 Better Health for African Mother and Child, Moshi,
a1111111111 Tanzania, 5 Division of Women, Oslo University Hospital, Rikshospitalet, Norway, 6 Elizabeth Glaser
Pediatric AIDS Foundation, Dar es Salaam, Tanzania
a1111111111
a1111111111 * [email protected]
a1111111111
Abstract
OPEN ACCESS
Citation: Masuke R, Msuya SE, Mahande JM, Diarz

Introduction
EJ, Stray-Pedersen B, Jahanpour O, et al. (2021) Childhood undernutrition is a major public health problem especially in low and middle-
Effect of inappropriate complementary feeding income countries (LMIC). The prevalence of early introduction of complementary feeding,
practices on the nutritional status of children aged
6-24 months in urban Moshi, Northern Tanzania:
low meal frequency, and low dietary diversity are frequent in LMICs. The effect of inappropri-
Cohort study. PLoS ONE 16(5): e0250562. https:// ate complementary feeding practices on the nutritional status of children is not well docu-
doi.org/10.1371/journal.pone.0250562 mented in East African countries including Tanzania. Therefore, this study aimed at
Editor: Marly A. Cardoso, Universidade de Sao determining the effect of inappropriate complementary feeding practices on the nutritional
Paulo Faculdade de Saude Publica, BRAZIL status of children aged 6–24 months in urban Moshi, Tanzania.
Received: October 26, 2020
Accepted: April 11, 2021

Methodology
Published: May 13, 2021
A retrospective cohort study was done using the Pasua and Majengo cohorts of mother-
child pairs in urban Moshi who were enrolled from 2002 to 2017. About 3355 mother-child
Copyright: © 2021 Masuke et al. This is an open
access article distributed under the terms of the
pairs were included in the analysis. Appropriate complementary feeding practices were
Creative Commons Attribution License, which assessed using WHO IYFP indicators such as age at introduction of solid, semi-solid, or soft
permits unrestricted use, distribution, and foods, minimum dietary diversity, and minimum meal frequency. Nutritional status (stunting,
reproduction in any medium, provided the original
wasting, and underweight) was determined. Multilevel modeling was applied to obtain the
author and source are credited.
effect of inappropriate complementary feeding practices on the nutritional status of children
Data Availability Statement: Dataset is publicly
and to account for the clustering effect of mothers and children and the correlation of
available and uploaded to the Figshare repository
(https://doi.org/10.6084/m9.figshare.13649984). repeated measures within each child.
Funding: The authors received no specific funding

for this work. Results
Competing interests: The authors have declared Majority of the children (91.2%) were given soft/semi-solid/solid foods before six months of
that no competing interests exist. age, 40.3percent had low meal frequency, and 74percent had low dietary diversity. Early
PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 1 / 16

PLOS ONE Effect of inappropriate complementary feeding practices on the nutrition status of children aged 6-24 months
introduction of complementary food at age 0–1 month was statistically significantly associ-
ated with higher risks of wasting and underweight (ARR 2.9, 95%CI 1.3–6.3; and ARR 2.6,
95% CI 1.3–5.1 respectively). Children with low minimum meal frequency had higher risks
of stunting, wasting, and underweight (ARR 2.9, 95%CI 2.3–3.6; ARR 1.9, 95%CI 1.5–2.5
and ARR 1.9, 95%CI 1.5–2.4 respectively). Children with low minimum dietary diversity
were more likely to be stunted than is the case with their peers who received the minimum
dietary diversity (ARR 1.3, 95% CI 1.01–1.6).
Conclusion
There were a high proportion of children, which were fed inappropriately; Inappropriate com-
plementary feeding practices predisposed children to undernutrition. Our study supports the
introduction of complementary feeding, providing minimum dietary diversity, and minimum
feeding frequency at six months of age as important in improving the nutritional status of the
children.
Introduction
An appropriate diet is a critical component for proper growth and development of children.
Appropriate child feeding practices in the first two years of life provide a critical window of
opportunity for the promotion of optimal growth and development [1]. The aspects of Infant
and Young Child Feeding Practices, which are important in the first 2 years of life include
early initiation of breastfeeding, exclusive breastfeeding, and timely and safe introduction of
complementary feeding with continued breastfeeding up to two years of age or beyond [2]. It
has been estimated that appropriate complementary feeding practices contribute to 17 percent
reduction in the prevalence of stunting at 24 months of age and could avert 6 percent of
under-five deaths each year [3, 4]. Suboptimal breastfeeding practices and infectious diseases
are the main immediate causes of undernutrition in the first two years of life [5].
WHO recommends an infant to be exclusively breastfed for the first six months of life, then
begin nutritionally adequate, safe, and appropriately-fed complementary foods from six to 24
months in order to meet the evolving needs of the growing infant [2]. However, few children
under two years of age are fed appropriately. Globally, it has been estimated that only 41per-
cent of infants are exclusively breastfed for six months, 25 percent receive the minimum die-
tary diversity (MDD) and 51 percent receive the minimum required meal frequency (MMF)
[6]. The highest burden of inappropriate complementary feeding practices are in low and mid-
dle-income countries [7]. Data from a recent Tanzania Demographic and Health Survey
showed that 59 percent of infants are exclusively breastfed for six months, 39 percent of chil-
dren aged 6–24 months are given minimum recommended meal frequency and 26 percent are
given minimum recommended diverse diet [8].
Despite the major progress in reducing the prevalence of child undernutrition, the burden
is still high in LMICs [9]. Globally, estimates show that 149 million of under-five children are
stunted and 49 million of under-five children are wasted. Low and middle-income countries
contribute to 65 percent of the stunted children and 73 percent of wasted children [10]. In
Tanzania, according to the Tanzania Demographic Health Survey stunting has been declining
from 48 percent in 2000 to 34 percent in 2015 (equal to 0.9% annual decrease), underweight
decreased from 24 to 14 percent while wasting remains at 5 percent in the same period [8].

This reveals a slow progress towards reaching global nutrition targets of reducing stunting by
40 percent in the year 2025.
Findings of the relationship between complementary feeding practices and child nutritional
status remain inconsistent [11]. Child undernutrition is still a significant public health prob-
lem and poor complementary feeding is a common practice for many mothers in East African
countries including Tanzania [12, 13]. However, the effect of inappropriate complementary
feeding practices on the child nutritional status remains unknown. Therefore, this study aims
at determining the effect of inappropriate complementary feeding practice on the nutritional
status of children. This may be an important aspect in devising strategies of influencing the
promotion of various nutrition interventions of reaching this most vulnerable population.
Methodology
Data source
This study was a part of a larger cohort established in 2002. Women recruited in the parent
study were from three distinct groups. The first group was recruited from 2002 to 2004, the
second group was recruited from 2005 to 2013, and the last group was recruited from 2014 to
2017. The main objective of the parent study was to investigate HIV and Sexually Transmitted
Diseases among pregnant women in Kilimanjaro [14]. The study included pregnant women
who were in their third trimester attending the antenatal care clinic at Pasua and Majengo
health centers in Moshi municipality, Kilimanjaro region. These two clinics were selected
because they have the largest number of clients and represent women from the largest geo-
graphical areas in urban Moshi [8]. Details of the methodology are documented elsewhere and
can be obtained from the previous studies [15–20].
Baseline data were collected during recruitment using a questionnaire designed to collect
information regarding maternal socio-demographic data, obstetric history, and behavioral and
employment status. Women and their children were followed up after delivery and each
mother-child pair was seen at the health centers after 3 months until the child turns 2 years of
age and thereafter a follow-up was after every 6 months until the child turns 5 years of age.
Four trained research assistants (two in each health facility) were taking anthropometrics and
collecting child feeding practices using a child questionnaire that was adopted from WHO
indicators for assessing IYCF practices [21]. This was modified to capture common foods con-
sumed in Moshi, Tanzania at each visit. Anthropometric measurements (height and weight)
were taken using the recommended WHO procedures [22]. The recumbent length (for chil-
dren below 24 months) was taken using a local made flat wood stadiometer. Weight of
undressed children was taken using SECA 813 digital scale (SECA, GmbH &Co.KG, Hamburg,
Germany) and the length and weight of children were taken to the nearest 0.1cm and 0.1g.
Study design and setting

This was a retrospective cohort study, which was carried out using data from Pasua, and
Majengo cohorts, which are health facilities located in the urban Moshi, Kilimanjaro region.
About 3355 mother-child pairs from 2002 to 2017 were included in this analysis. The following
were the inclusion criteria: mother-child pairs with any follow-up visit from 6 to 24 months
having anthropometrics and feeding data (Fig 1).
Variables measurements
Dependent variables. Dependent variables were stunting [height-for-age (HAZ)], wasting
[weight-for-height (WHZ), and underweight [weight-for-age (WAZ)]. Children were

Fig 1. Flow chart for selecting mother-infant pairs to be included in the study.
https://doi.org/10.1371/journal.pone.0250562.g001
classified as stunted, wasted or underweight if their Z-scores were <-2 Standard Deviation
(SD) [23].
Independent variables. Inappropriate complementary feeding practices were defined as
the introduction of complementary foods that fails to meet either of the three indicators of
time of introduction (six months of age), minimum meal frequency or minimum dietary
diversity [1]. Therefore, to assess inappropriate complementary feeding practices, three pri-
mary independent variables were used, which were the introduction of solid, semi-solid, or
soft foods, minimum dietary diversity, and minimum meal frequency. Each of these indicators
was measured separately.
Introduction of solid, semi-solid, or soft foods was measured as the age of a child in months
when soft foods/semi-solid foods/solid foods were introduced. Mothers/caregivers reported
when a child started receiving soft-foods, semi-solids, and solid foods. Introduction of solid,
semi-solid, or soft foods was further categorized as early introduction of complementary feed-
ing (grouped as 0–1 month, 2-3months, 4–5 months), and appropriate age of introduction of
complementary feeding (as 6–8 months of age) [21].
The 7 food groups were used for the calculation of WHO minimum dietary diversity indi-
cator, which are (i) grains, roots and tubers, (ii) legumes and nuts, (iii) dairy products, (iv)
flesh foods, (v) eggs, (vi) vitamin A-rich fruits and vegetables, and (vii) other fruits and vegeta-
bles. The dietary diversity score ranged from 0 if none of the food groups is consumed to 7 if
all the food groups are consumed. Minimum dietary diversity was constructed from the die-
tary diversity score using the WHO recommended cut-off point with a value of “1” if the child
had consumed four or more groups of foods (minimum dietary diversity) and “0” if the child

consumed less than four food groups (low dietary diversity). MDD was estimated during 6, 9,
12, 15 and 24 months visit by asking mothers/caregivers to report the food and liquid con-
sumed during the previous day of the visit as per the WHO guidelines.
Minimum meal frequency was a self-reported question on the number of times per day a
child received complementary foods on the day before the visit. MMF was estimated at each
visit and a child was judged to have taken an adequate number of meals if he/she received at
least the minimum frequency of feeding. This means, 2 times for 6–8 months and 3 times for
9–11 months, 3 times for children aged 12–23 months for breastfed children and 4 times for
non-breastfed children. Appropriate feeding frequency was coded as 1 (minimum meal fre-
quency) and inappropriate was coded 0 (low meal frequency) [21].
Other potential predictors in this study included sex of the baby (male vs female), prematu-
rity (normal vs premature babies), and birth weight (normal and low birth weight as <2.5kg),
breastfeeding duration (continue breastfeeding in months), and mothers’ age in years (<24,
25–34, >35). Others include mothers’ education level (no education, primary, secondary and
higher education level), marital status (single, married/cohabiting and divorced/separated),
alcohol intake (yes, no), and HIV status (positive, negative). Others include religion (Christian,
Muslim), employment status (formal and informal employment), gravidity (1, 2–4, >4), parity
(0, 1–4, >4), socioeconomic status (low, medium and high socio-economic status), multiple
births (singleton and twins), and the number of visits at the clinic and enrollment year.
Statistical analysis
Data were extracted from women and infant questionnaires of the parent study using EpiInfo
7.1.5.2 database and the analysis were done in StataCorp version 14.0. The overall proportion
of stunting, wasting, and underweight was calculated and further analysis was done across the
follow-up visits to see the peak of undernutrition. The proportion of children with suboptimal
complementary feeding practices across the cohort and at different age points during the fol-
low-up visit was calculated. A chi-squared test was used to determine any statistical difference
in the proportion of children with inappropriate feeding practices across the nutrition
indicators.
Mother-child pairs were followed from birth with repeated measurements done at 6, 9, 12,
15, and 24-months visits (including anthropometric measurements, food groups consumed,
and feeding frequency). Some mothers had more than one pregnancy in the cohort hence
there was a possible similarity among children of the same mother than those of different
mothers. Therefore, to account for the correlation of repeated measures within a child and
clustering effect of mothers and their children, multilevel modeling using “gllamm” a Stata
command specifying cluster variable (mother-child), family (binomial), and link function
(logit) were used. Mothers were cluster level three, each child was a cluster in level two, and
repeated measures done in a child was a level one cluster.
Data were transformed into a long format. An empty model with no exposure variable was
done to determine the total variability in stunting, wasting, and underweight that can be
explained by clusters (ICC). To test the significance of each level of a cluster, the likelihood
ratio test was used by comparing a model without a cluster versus a model with a cluster level.
A nested model was considered important at the significant level of 5 percent. Univariable
multilevel logistic regression analysis was done for factors in each cluster’s level (from level
one to three) and factors that remained to be significant at a p-value of <10% were retained
for a multivariable model. Fixed and random effects were tested and the final model comprises
of a combined model with level 1, 2 and 3 factors. Therefore, multilevel logistic regression
analysis was used to estimate the adjusted relative risk (ARR) with their 95 percent confidence

interval for the effect of inappropriate complementary feeding practices and nutritional status
of the children.
Ethical consideration
Ethical approval was obtained from the Research Ethical Committee of Kilimanjaro Christian
Medical University College (CREC No. 2411). The permission to use Pasua and Majengo
cohort data was obtained from the Better Health for African Mother and Child (BHAMC)
project. Written consents were obtained from mothers and numbers were used to identify par-
ticipants instead of names to ensure confidentiality. All participants’ information was kept and
analyzed anonymously.
Results
Baseline characteristics
About 3355 children aged 6–24 months were included in the analysis. The overall follow-up
rate was 85 percent and follow-up rates at visit months 6, 9, 12, 15, and 24 were 86, 87, 88, 88,
and 66 percent respectively. Some children were lost due to the absence of the mother at the
clinic during the follow-up visit.
Total mothers in this analysis were 2774, each mother had 1 to 6 children, and each child
had repeated observations ranging from 1 to 7 occasions/visits. The mean age of mothers at
recruitment was 25.6 (SD ± 5.01) years and their partners’ age was 31.7 (SD ± 6.3) years. Most
mothers (89.5%) were either married or cohabiting and 74.8 percent had primary level educa-
tion. The majority (81.8%) had only one pregnancy in the cohort while others had up to six
pregnancies. Regarding the children’s characteristics, 57 percent of the babies born in the
cohort were males and the mean birth weight was 3.2 (SD ± 0.49) (Table 1).
Nutrition status of children aged 6–24 months

The overall proportion of stunting, wasting, and underweight was 20.7, 8.9, and 9.7 respec-
tively. All three indicators of undernutrition started declining from six to 24 months of age.
Stunting was the most prevalent condition but a high proportion of children who were
stunted, underweight, and wasted were observed within the first nine months of life (Fig 2).
Complementary feeding practices

The mean age of introduction of complementary food was 3 months. The majority of children
(39.9%) were initiated complementary food between 2 to 3 months of age, whereby only 8.8
percent reached the recommended age of 6 months (Fig 3). The majority of children (91.2%)
were introduced to complementary food before six months, the majority of children (73.9%)
had low dietary diversity, and 40.4 percent had low meal frequency (Fig 4).
The proportions of children who adhered to the minimum dietary diversity slightly
increased across follow-up months. While on the other hand, the proportions of children who
adhered to the minimum meal frequency decreased across the follow-up visit (Fig 5).
The highest proportion of children, who were stunted, wasted, and underweight was
observed among children who were introduced to complementary feeding before the recom-
mended age of 6 months. This shows a significant difference in the proportion of children who
were stunted, wasted, and underweight across age categories at which complementary feeding
was introduced with p-value <0.01 (Fig 6).

Table 1. Child and maternal baseline characteristics (N = 3355).

Variables Frequency Percent
Sex of the child
Male 1,922 57.3
Female 1,433 42.7
Premature or term
Term 3,308 98.6
premature 47 1.4
Singleton or twin
Singleton 3,316 98.8
Twin 39 1.2
Age of the mother
<24 1,408 42.0
25–34 1,759 52.4
>35 188 5.6
Education Level
None 103 3.1
Primary 2,509 74.8
Secondary and above 743 22.2
Employment Status
Informal employment 2,407 71.7
Formal employment 948 28.3
Marital status
Married/cohabiting 3,002 89.5
Single 221 6.6
Widowed/divorced/separated 132 3.9
Gravidity
Gravid 1 1,291 38.5
Gravid 2–4 1,824 54.4
More than 4 240 7.1
Parity
0 1,291 38.5
1–4 1,951 58.2
Above 5 113 3.4
Alcohol intake
No 2,318 69.1
Yes 1,037 30.9
Mode of Delivery
Vaginal Delivery 3,025 90.2
Caesarean section 330 9.8
HIV Status
Negative 2,893 86.2
Positive 462 13.7
Age of the partner
< = 24 457 13.6
>24 2,898 86.4
Education of the partner
None 28 0.8
Primary 2,661 79.3
(Continued )

Table 1. (Continued)
Variables Frequency Percent

Secondary and above 666 19.9
Socio-economic status� (N = 1436)
Low 545 38.0
Medium 549 38.2
High 342 23.8
�
Variable with missing information
https://doi.org/10.1371/journal.pone.0250562.t001
Multilevel regression analysis for the effect of inappropriate

complementary feeding practices on nutritional status of the children
After adjusting for the child and maternal characteristics, infants that were introduced to com-
plementary foods at age 2–3 months had approximately 2 times higher risk of being stunted
(ARR 1.88, 95%CI 1.06–3.36, p = 0.032). Infants that were introduced to complementary foods
at age 0–1 month had 2.9 and 2.6 times higher risk of being wasted and underweight as com-
pared to those who were introduced to complementary foods between 6–8 months (ARR 2.86,
95% CI: 1.30–6.29, p = 0.009 and ARR 2.57 95%CI: 1.29–5.14, P = 0.007).
Children who did not receive the minimum meal diversity had 29 percent higher risk of
stunting compared with children who received the minimum meal diversity (ARR 1.29, 95%
CI 1.01–1.64, p = 0.041). Children who did not receive the minimum meal frequency had
approximately 3 times higher risk of stunting (ARR 2.87, 95%CI 2.30–3.59, p < 0.001). Infants
Fig 2. Proportion of children with undernutrition across follow up months.


Fig 3. Distribution of children according to age at introduction of complementary feeding.

who did not receive the minimum meal frequency had 93 and 89 percent higher risk of wasting
and underweight, respectively, as compared with children who received the minimum meal
frequency (ARR 1.93 95% CI 1.49–2.46, p<0.001 and ARR 1.89; 95% CI 1.52–2.35, p < 0.001)
(Table 2).
Discussion
The result of this study showed that suboptimal complementary feeding practices were com-
mon in urban Moshi. Early introduction of complementary feeding before 6 months was asso-
ciated with a higher risk of stunting, wasting, and underweight. Children aged 6–24 months
with low minimum meal frequency were more likely to be stunted, wasted, and underweight.
Children with low MDD were likely to be stunted.
Our findings show that about 91 percent of the children were given complementary food
before the age of 6 months. This was higher than the national prevalence of 41 percent from
the 2015/16 Tanzania Demographic Health Survey and was slightly higher for Kilimanjaro
region of 85.4 percent [8]. The differences in the study design could be the reason for the
observed differences since the TDHS is a cross sectional study and only one data point is col-
lected, whereas this was a cohort study with minimum recall bias. Similar results have been
reported in a study carried out in Kenya which found 98 percent of infants were comple-
mented before the age of 6 months [24]. The main reason for this high proportion of inappro-
priate age of introducing complementary food could be the mothers’ perception that breast
milk is insufficient for a child’s growth as reported in a study carried out in Tanga, northern
Tanzania [25]. Therefore, health education to mothers is essential in promoting appropriate
age of introduction of complementary feeding especially during the ante and post-natal period
[26].

Fig 4. Proportion of inappropriate complementary feeding practices among children aged 6–24 months.
Fig 5. Proportion of children who adhered to the minimum meal frequency and minimum dietary diversity across follow up visits.

Fig 6. Proportion of children with undernutrition with respect to age category at which complementary feeding was introduced.
Our findings show the prevalence of, 26 percent of low MDD, which is similar to the national
level [8]. It is common in this setting for the infant to receive porridge, “mtori,” or “kitawa”
when they reach six months of age as it is perceived to be the food for infants and that infants
Table 2. Multilevel logistic regression: Effect of inappropriate complementary feeding practices on the nutrition status of the children.
Variables Stunting Wasting Underweight
CRR (95% CI) ARR(95% CI) CRR (95% CI) ARR(95% CI) CRR (95% CI) ARR(95% CI)
Age of introduction of Complementary
Feeding
6–8 months 1 1 1 1 1 1
0–1 months 0.89 (0.64–1.24) 1.41 (0.77–2.16) 1.75 (1.07–2.84)� 2.86 (1.30–6.29)�� 1.68(0.97–2.93) 2.57 (1.29–5.14)��
2–3 months 1.40 (1.03–1.91)� 1.88 (1.06–3.36)� 1.29 (0.81–2.06) 1.75 (0.81–3.77) 1.64(0.81–2.36) 1.68 (0.85–3.32)
4–5 months 1.30 (0.95–1.78) 1.42 (0.78–2.59) 1.43 (0.89–2.30) 1.95 (0.89–4.28) 1.93(1.09–3.21)� 2.14 (1.08–4.29)�
Minimum Dietary Diversity
MDD 1 1 1 1 1
Low MDD 1.02 (0.89–1.16) 1.29 (1.01–1.64)� 1.05 (0.87–1.27) 1.19 (0.89–1.57) 1.17 (0.95–1.43) 1.13 (0.89–1.44)
Minimum Meal Frequency
MMF 1 1 1 1 1
Low MMF 3.15 (2.80– 2.87 (2.30– 1.37 (1.17– 1.93 (1.49– 1.38 (1.18– 1.89 (1.52–
3.54)�� 3.59)�� 1.60)�� 2.49)�� 1.63)�� 2.35)��
CRR = Crude Risk Ratio

ARR = Adjusted Risk Ratio; Risk Ratio Adjusted for sex of the baby, premature and birth weight, breastfeeding duration, mothers’ age, mother’s education level, marital
status, alcohol intake, HIV status, religion, number of visits and enrollment year.
�
Significant at p<0.05
��
��
https://doi.org/10.1371/journal.pone.0250562.t002

cannot eat other foods such as vegetables and animal products. It has been reported that poor
dietary diversity is a common practice in SSA countries and starch-based foods such as porridge
is the commonly given food [27]. A study in Nigeria, Zambia, and Ethiopia also reported a low
rate of dietary diversity [28, 29]. In Nigeria, inadequate maternal nutrition knowledge on child
feeding or economic reasons were cited as among the contributing factors [29].
In our study, MMF was observed to be about 60 percent, which was higher than the
reported 39 percent at the national level [8]. A comparable result was reported in Zambia
and Ethiopia [28]. The reason for this could be food preparation, as reported earlier that
the common food given is porridge, “mtori,” or “kitawa.” It is common to prepare these
foods mostly in the morning and put it in a flask where a mother or another family member
could feed the infant throughout the day hence receiving the required number of meals in a
day.
Our findings indicated that early introduction of complementary feeding was significantly
associated with a higher risk of stunting, wasting, and underweight. Studies done in Zambia,
Ghana, and Nigeria reported similar findings [28–30]. Early introduction of complementary
feeding is linked with a substantially increased risk of recurrent diarrhoea and other infectious
diseases resulting in undernutrition [31, 32]. In LMICs, access to clean and safe water is a chal-
lenge leading to microbial contamination of complementary foods through unsafe preparation
and storage. On the other hand, the gastrin intestinal track of an infant below six months of
age is not fully developed to digest other foods apart from breast milk [33–36]. Therefore,
there is a need of continuing providing education on the advantages of exclusive breastfeeding
to mothers/caregivers. This can be done during antenatal care, delivery, postnatal visits, and
monthly child growth monitoring visits.
Our findings also showed that children who received low minimum meal frequency were
more likely to be stunted, wasted, and underweight than is the case with their peers. Our find-
ings were similar to the findings of other studies in most low and middle-income countries
[11, 29]. The minimum number of meals per day is required in order to attain the necessary
level of energy and nutritional requirement and prevent deficiencies that could result into
undernutrition [37]. These findings are in contrast with the findings in a study done in Ghana
which found that minimum meal frequency was not associated with stunting [30]. The appar-
ent lack of association in this study may be because there was very little variation in the study
population with respect to this indicator.
Low MDD was associated with stunting and not wasting or underweight. Our findings
were in line with the findings in other studies that used a variety of indicators aimed at captur-
ing food variety or dietary diversity in most low and middle-income countries [11, 28, 29, 38–
40]. This is because a more diversified diet is highly correlated with adequate energy and pro-
tein, micronutrients, and animal source food [41, 42]. The inadequate intake of a quality diet is
among the main contributing factors for undernutrition [43]. We also anticipate a significant
contribution of maternal nutrition to children’s diet and nutritional status. However, the par-
ent study did not capture variables that assessed the nutritional status of women and dietary
habits during pregnancy. Hence, we recommend future studies to establish the contribution of
maternal nutrition to the infant’s diet and nutritional status.
Strength and limitation of the study

The strength of this study was that this was the first study to examine the effect of inappropri-
ate complementary feeding practices on the child’s nutritional status in Tanzania. The close
follow-up of mother-child pairs provide more accurate estimates of the effect of complemen-
tary feeding practices on the child’s nutritional status. Hierarchical modelling of the data

provided more reliable estimates as it accounts for the correlation of the repeated measure-
ments and the effect of clustering [44, 45].
Despite the strength of this study, some limitations had to be taken into account while
interpreting the findings. First, there was a loss to follow-up bias of about 14.3 percent. There-
fore, the information of those who were lost was not analyzed. However, this rate was low
compared to the recommended threshold level [46]. In addition, we missed some variables
such as those of assessing maternal health during pregnancy (as parent study recruited women
in their third trimester), which could have the potential effect on children’s diet and nutritional
status. Therefore, the significant contribution of maternal nutrition was not assessed.
Conclusion and recommendation

We observed a high proportion of children with suboptimal complementary feeding practices.
Early introduction of complementary food increased the risk of stunting, wasting, and under-
weight. Children who had low meal frequency were more likely to be stunted, wasted, and
underweight than was the case with their counterparts. Children who had low dietary diversity
were more likely to be stunted.
There is a need for Tanzania’s Ministry of Health and other stakeholders to formulate strat-
egies for educating mothers both in the health facility and in the community on the impor-
tance of adhering to the recommended age of introduction of complementary feeding, meal
frequency, and dietary diversity. Also, health care providers should be informed on the low
proportion of adherence to the recommended complementary feeding practices so that they
can discuss with mothers/caregivers the importance of optimal complementary feeding prac-
tices during ANC, delivery, postnatal visit and also during child growth monitoring and vacci-
nation visits. Future studies are recommended to assess women’s knowledge and
understanding of optimal complementary feeding practices so as to know the reasons for the
observed high proportion of children with suboptimal complementary feeding. In addition,
other studies should establish the contribution of maternal nutrition on infants’ diet and nutri-
tional status.
Supporting information
S1 Appendix. Additional tables for multilevel logistic regression for the effect of inappro-
priate complementary feeding practices on the nutritional status of the children aged 6–24
months.
(DOCX)
S1 File. A copy of questionnaire.
(PDF)
Acknowledgments
We would like to express our gratitude to the Institute of Public Health specifically the Depart-
ment of Epidemiology and Biostatistics at Kilimanjaro Christian Medical University College
for making it possible to carry out this study. In addition, we would like to thank the Better
Health for African Mother and Child project for their faithful participation in seeing this work
through to publication. The authors are grateful for the assistance provided by Ms. Kabula
Jahanpour in editing this manuscript.

Author Contributions
Conceptualization: Rachel Masuke, Sia E. Msuya, Johnson M. Mahande, Ester J. Diarz, Ola
Jahanpour, Melina Mgongo.
Data curation: Rachel Masuke, Johnson M. Mahande, Ola Jahanpour.
Formal analysis: Rachel Masuke, Johnson M. Mahande, Ola Jahanpour.
Investigation: Rachel Masuke, Ester J. Diarz, Babill Stray-Pedersen, Melina Mgongo.
Methodology: Rachel Masuke, Johnson M. Mahande, Ester J. Diarz, Ola Jahanpour.
Project administration: Rachel Masuke, Sia E. Msuya, Babill Stray-Pedersen, Melina Mgongo.
Resources: Rachel Masuke.
Software: Rachel Masuke.
Supervision: Rachel Masuke, Sia E. Msuya, Johnson M. Mahande, Babill Stray-Pedersen,
Melina Mgongo.
Validation: Rachel Masuke, Sia E. Msuya, Johnson M. Mahande, Melina Mgongo.
Visualization: Rachel Masuke, Ola Jahanpour, Melina Mgongo.
Writing – original draft: Rachel Masuke.
Writing – review & editing: Rachel Masuke, Sia E. Msuya, Johnson M. Mahande, Ester J.
Diarz, Babill Stray-Pedersen, Ola Jahanpour, Melina Mgongo.
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PLOS ONE

Effect of inappropriate complementary

Citation: Masuke R, Msuya SE, Mahande JM, Diarz

Accepted: April 11, 2021

Funding: The authors received no specific funding

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 1 / 16

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 2 / 16

Study design and setting

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PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 5 / 16

Nutrition status of children aged 6–24 months

Complementary feeding practices

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 6 / 16

Table 1. Child and maternal baseline characteristics (N = 3355).

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Variables Frequency Percent

Multilevel regression analysis for the effect of inappropriate

Fig 2. Proportion of children with undernutrition across follow up months.

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 8 / 16

Fig 3. Distribution of children according to age at introduction of complementary feeding.

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 9 / 16

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 10 / 16

CRR = Crude Risk Ratio

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 11 / 16

Strength and limitation of the study

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Conclusion and recommendation

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PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 14 / 16

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 15 / 16

PLOS ONE | https://doi.org/10.1371/journal.pone.0250562 May 13, 2021 16 / 16

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