Public Health Nutrition: 22(1), 104–114 doi:10.

1017/S136898001800294X

Infant and young child feeding practices, sociodemographic

factors and their association with nutritional status of children
aged <3 years in India: findings of the National Nutrition
Monitoring Bureau survey, 2011–2012
Indrapal Ishwarji Meshram*, K Mallikharjun Rao, Nagalla Balakrishna, R Harikumar,
N Arlappa, Kakani Sreeramakrishna and Avula Laxmaiah
Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Jamai-Osmania
(PO), Hyderabad – 500007, Tarnaka, India

Submitted 16 May 2018: Final revision received 7 September 2018: Accepted 25 September 2018: First published online 6 November 2018

Abstract
Objective: To study infant and young child feeding (IYCF) practices and their
association with nutritional status among young children.
Design: A community-based, cross-sectional study was carried out in ten states of
India, using a multistage random sampling method. Anthropometric measure-
ments such as length/height and weight were conducted and nutritional
assessment was done using the WHO child growth standards.
Setting: National Nutrition Monitoring Bureau survey, 2011–2012.
Participants: Children aged <3 years and their mothers.
Results: Only 36 % of infants received breast-feeding within an hour of birth and
50 % were exclusively breast-fed up to 6 months. Prevalence of underweight,
stunting and wasting was 38, 41 and 22 %, respectively. The chance of
undernutrition among <3-year-old children was significantly higher among those
from scheduled caste/scheduled tribe communities, the lowest-income group,
with illiterate mothers and lack of sanitary latrine. Among infants, the chance of
undernutrition was significantly higher among low-birth-weight babies, and
among children whose mother had not consumed iron–folic acid tablets during
pregnancy. Immunization practices and minimum dietary diversity were observed
to be associated with undernutrition among 12–23-month-old children.
Keywords
Conclusions: Undernutrition is still an important public health problem in India
Undernutrition
and observed to be associated with low socio-economic status, illiteracy of Infant and young child
mother, low birth weight and dietary diversity. Improving socio-economic and feeding practices
literacy status of mothers can help in improving maternal nutrition during Conceptual framework
pregnancy and thus low birth weight. Also, improving knowledge of mothers Nutritional assessment
about IYCF practices will help in improving children’s nutritional status. Minimum dietary diversity

Undernutrition continues to be an important public health feeding for 6 months and continued breast-feeding until
problem in India, despite several nutrition intervention age 2 years or longer – has the potential to prevent 12 % of
programmes in operation over the last four decades. all deaths in under-5s(1).
Undernutrition is responsible directly or indirectly for Poor feeding practices during infancy and early child-
about 45 % of deaths among children under 5 years of age hood, resulting in malnutrition, contribute to impairment
(under-5s) globally, with these children at higher risk of of cognitive and social development, poor school
death from common childhood illness such as diarrhoea, performance and reduced productivity in later life(3).
pneumonia and malaria(1). Of this, about two-thirds are Exclusively breast-fed children are less susceptible to
attributable to suboptimal infant and young child feeding diarrhoea and pneumonia and are fourteen times more
(IYCF) practices and occur during first year of life(2). In likely to survive than non-breast-fed children(4). IYCF is a
developing countries, optimal breast-feeding – that is, key area to improve child survival and promote healthy
breast-feeding within an hour of birth, exclusive breast- growth and development. The first 2 years of a child’s life

*Corresponding author: Email [email protected] © The Authors 2018

IYCF practices and nutritional status 105
(11)
are particularly important, as optimal nutrition during this Census of India . From each selected village, twenty
period lowers morbidity and mortality, reduces the risk of households (HH) were covered after dividing the village
chronic disease and fosters better development overall. into five geographical areas based on streets/mohallas/
Many studies have shown beneficial effects of breast- areas. It was ensured that at least one of the five areas was
feeding on infant mortality, respiratory infections, diar- inhabited by scheduled caste (SC)/scheduled tribe (ST)
rhoea(4) and neonatal sepsis(5–9) and thus on nutritional communities, which are officially designated groups of
status. Suboptimum breast-feeding was estimated to be historically disadvantaged people as per the Constitution
responsible for 1·4 million child deaths and 44 million of India, and the groups in the other areas were desig-
disability-adjusted life years (10 % of disability-adjusted life nated in one or other of the population categories wher-
years in under-5s) for the year 2004(2). WHO has recom- ever possible to give equal representation to all
mended breast-feeding to be initiated early after birth, communities. From each area, four contiguous HH were
preferably within an hour, avoidance of prelacteal feeds covered by randomly selecting the first HH. Thus, a total
and exclusive breast-feeding up to first 6 months. of twenty HH were covered in each village and 2400 HH
UNICEF has set seventeen developmental goals under in each state. All children <3 years of age present at the
the Sustainable Development Goals 2015(10), officially time of the survey were included in the study.
known as Transforming Our World: The 2030 Agenda for
Sustainable Development, which include poverty allevia-
Data collection
tion, ending hunger, achieving food security and
Data were collected by a team comprising a medical
improved nutrition, and promoting sustainable agriculture.
officer, a nutritionist and a social worker in each state, who
Improving nutrition includes: ending all forms of mal-
were trained and standardized in survey methodologies
nutrition, such as reducing stunting and wasting in under-
by scientists from the National Institute of Nutrition,
5s by 2025 as agreed internationally; addressing the
Hyderabad. All survey schedules were pre-tested before
nutritional needs of adolescent girls, pregnant and lactat-
being used in the field. Information on household socio-
ing women and older persons; and reducing the global
economic and sociodemographic characteristics, such as
maternal mortality rate to less than 70/100 000 live births,
community, religion, education, occupation and income,
the neonatal mortality rate to as low as 12/1000 live births
were collected using a pre-tested proforma. IYCF practices
and the under-5 mortality rate to 25/1000 live births(10).
such as initiation of breast-feeding, age at initiating com-
These targets can only be achieved by improving
plementary feeding, colostrum feeding, etc. were also
maternal and adolescent nutrition, proper health-care
collected from mothers of children aged <2 years.
services, control of childhood diseases and reducing
Anthropometric measurements of the children were
undernutrition among under-5s.
collected. Length/height (up to nearest 1 mm) was mea-
The present study was carried out by the National
sured with an infantometer/anthropometer rod and weight
Nutrition Monitoring Bureau (NNMB) on ‘diet and nutri-
(up to nearest 100 g) with a SECA weighing scale (SECA
tional status of the rural population in India’ during 2011–
Deutschland, Hamburg, Germany) using standard
2012. Data pertaining to IYCF feeding practices and their
anthropometric procedures(12). History of morbidity such
influence on nutritional status are presented in the
as fever, respiratory infection, diarrhoea, etc., if any,
current paper.
during the 15 d preceding the visit was also collected.

Methods Definitions
‘Household’ is defined as those living together under one
Study design and setting roof and sharing a common kitchen.
A community-based, cross-sectional study was carried out ‘Pucca house’ means walls made of cement and bricks
in ten states in India (Kerala, Tamil Nadu, Karnataka, or stones with a reinforced cement concrete roof; a ‘semi-
Andhra Pradesh, Maharashtra, Gujarat, Madhya Pradesh, pucca house’ is one that has brick or stone walls and a
Orissa, West Bengal and Uttar Pradesh) adopting a mul- tiled or asbestos roof; while a ‘kutcha house’ has mud or
tistage random sampling procedure. A total of 120 villages thatched walls and a thatched or tiled/asbestos roof.
were covered in each NNMB state. ‘Minimum dietary diversity’ is the number of different
foods or food groups consumed over a given reference
period and is said to be met by the consumption of four or
Selection of villages and households more food groups in a diet.
From each state, the villages were selected based on ‘Prelacteal feeds’ are those foods given to a newborn
probability proportional to size of the population. Ninety before breast-feeding is established or before breast milk
villages were selected from those covered in previous ‘comes in’, usually on the first day of life, and include
surveys and the remaining thirty villages were randomly honey, jaggery (brown sugar from sugarcane), ghee
selected afresh from the list of villages obtained from the (clarified butter) and ghutti (herbal paste).
106 II Meshram et al.
‘Exclusive breast-feeding’ means giving only breast gender remained in the model together with significant
milk, not even water, up to 6 months. distal factors, while intermediate factors (such as age and
parity of mother, education of mother, place of delivery,
birth weight, sanitary latrine and hand-washing practices
Ethical approval
of mother) were added, which constituted the second
The study was approved by the Institutional Ethical
stage. The proximal variables (including breast-feeding
Committee of the National Institute of Nutrition as well as
practices, age at initiation of complementary feeding and
the Scientific Advisory Committee. Written informed
morbidities during the preceding fortnight) were added in
consent was obtained from the mothers involved in the study.
the third stage.
The nutritional status of children was assessed accord-
Data analysis ing to SD classification(14) using the WHO Child Growth
The data were scrutinized and entered on computer at the Standards(15). Children who were below 2 SD from the
National Institute of Nutrition, Hyderabad. Data cleaning reference median (median < − 2 SD) on the basis of weight-
was done by carrying out range and consistency checks, for-age, height-for-age and weight-for-height indices were
then data analysis was conducted using the statistical classified as underweight, stunted and wasted, respec-
software package SPSS Statistics for Windows version 17.0. tively; while children who were below 3 SD from the
Tests of proportions (χ2 test) and bivariate analyses reference median (median < − 3 SD) were classified as
(logistic regression) were carried out, and multivariate severely underweight, severely stunted and severely
logistic regression analyses were done according to the wasted, respectively.
conceptual hierarchical framework developed by Victora
et al.(13). Figure 1 shows the factors controlled for in
hierarchical order for underweight, stunting and wasting, Results
which was the basis for adjusted logistic regression ana-
lyses. Age and gender were considered inherent factors Coverage
and were controlled for in all models and at each stage A total of 4038 (2095 boys, 51·9 %) children aged
irrespective of significance level. The distal factors (such 0–35 months were covered for IYCF practices and
as community, per capita income (tertile), type of house anthropometric measurements. The mean age of the
and landholding) constituted the first stage. Age and children was 16·3 (SD 9·5) months.

Distal factors
Age and gender • Household wealth
• Land ownership
• Community

Intermediate factors
• Mother’s age and parity
• Parents’ education and occupation
• Birth order and weight
• Delivery and hygiene practices
• Immunization

Proximal factors
• BF and young child feeding
• Prelacteal feeds colostrum
• Age at CF, morbidity

Nutritional status of children

aged < 5 years

Fig. 1 (colour online) Factors controlled for in hierarchical order in the adjusted logistic regression analyses for underweight,
stunting and wasting (BF, breast-feeding; CF, complementary feeding)
IYCF practices and nutritional status 107
Sociodemographic characteristics Association of antenatal care, delivery and feeding
The majority (88·6 %) of children belonged to the Hindu practices with undernutrition among 0–11-month-
religion, while 7 % were Muslims; 14 % belonged to ST old children using bivariate analyses
communities, 26 % to SC and 35 % were from the other The odds of being underweight were 2·90 times higher
backward caste category. About 44 % were living in a among children whose mothers did not attend antenatal
kutcha house, 34 % in a semi-pucca house, while only check-ups compared with those whose mothers had four
23 % had a pucca house. About 43 % belonged to a or more antenatal visits; and about 2·5 times higher among
nuclear family while 38 % were from joint families, 78 % of children whose mothers had not consumed or consumed
houses had electricity, 39 % of HH were using tap water fewer than ninety iron–folic acid (IFA) tablets during
for drinking purposes and 29 % of HH had a sanitary pregnancy, compared with those whose others consumed
latrine. Monthly per capita income was Rs 1083 only. ninety IFA tablets or more. The odds of underweight were
1·61 times higher among children delivered at home than
among those delivered at hospital and 2·22 times higher
Feeding practices of infants among children with low birth weight than among those
Only 36 % of the mothers initiated breast-feeding within with normal weight at birth. Similarly, the odds of stunting
1 h of birth, while 15 % did so after 24 h. About 50 % of were higher among children delivered at home and
children were exclusively breast-fed up to 6 months. among low-birth-weight children. The odds of wasting
Among children aged 6–11 months, 54 % had com- were higher among children whose mothers did not attend
plementary feeding initiated at 6–7 months old. Minimum antenatal check-ups and among children whose mothers
dietary diversity was observed among 31 % of did not consume or consumed fewer than ninety IFA
6–11-month-old children while it was 85 % among tablets during pregnancy. Only stunting was observed
12–23-month-old children. to be significantly associated with minimum dietary
diversity (child’s consumption of four or more food
groups; OR = 1·56; 95 % CI 1·10, 2·21; Table 2).

Prevalence of undernutrition among children

The prevalence of underweight, stunting and wasting Undernutrition in relation to feeding practices
was 38, 41 and 22 %, respectively, and all prevalences among 0–11-month-old children
except wasting were lower among girls (36 % under- Among 0–5-month-old children, it was observed that
weight, 39 % stunted) compared with boys (40 and 44 %, undernutrition prevalence was low among exclusively
respectively). breast-fed infants up to 4 months of age; at age 5 months,
the prevalence was higher among exclusively breast-fed
children compared with those receiving complementary
feeding in addition to breast milk. Among 6–11-month-old
Association between sociodemographic
children, the prevalence of underweight and stunting was
characteristics and undernutrition using
lower among children who received complementary
bivariate analyses
feeding in addition to breast milk at age 6–8 months
The odds of being underweight were 1·91 times higher
compared with those who were exclusively breast-fed or
among children aged 12–35 months compared with 0–11-
those who received complementary feeding after 8
month-olds. The odds of being underweight were 1·28
months.
times higher among boys than girls. The odds of under-
weight were 2·89 and 1·60 times higher among children
belonging to ST and SC compared with others; 1·57 times Association of complementary feeding practices
higher among children belonging to nuclear families and immunization with undernutrition among
compared with joint families; 2·17 times higher among 12–23-month-old children
children of illiterate mothers compared with children of The prevalence of underweight and wasting was observed
the most highly educated mothers (9th grade or above); to be high among children who were exclusively breast-
2·56 times higher among children from HH with per capita fed (78·6 and 50·0 %, respectively) compared with children
income in the first tertile compared with children from HH who received complementary feeding in addition to breast
with per capita income in the third tertile; and 2·38 times milk (43·7 and 22·0 %, respectively). Underweight and
higher among children belonging to HH not having a stunting prevalences were observed to be high among
sanitary latrine. Similarly, the odds of stunting and wasting children who received complementary feeding after age
were higher among 12–35-month-olds, among boys, 8 months (45·2 and 58·0 %, respectively) compared
among children belonging to ST and SC communities, with children who received complementary feeding at
among children from nuclear families, of illiterate mothers, 6–8 months of age (40·8 and 52·9 %, respectively). It was
from HH with per capita income in the first tertile and from also observed that the prevalence of underweight and
HH not having the facility of a sanitary latrine (Table 1). stunting was higher among partially immunized or not
108 II Meshram et al.
Table 1 Bivariate analyses of undernutrition according to age, gender and socio-economic status among Indian children aged <3 years,
National Nutrition Monitoring Bureau survey, 2011–2012

Underweight Stunting Wasting

Characteristic n OR 95 % CI OR 95 % CI OR 95 % CI
Age group (months)
0–11 1436 1.00 Ref. 1.00 Ref. 1.00 Ref.
12–35 2602 1.91 1.66, 2·19 3.32 2·88, 3.83 0.64 0.55, 0.74
Pooled 4038
Gender
Boys 2095 1.28 1.13, 1.46 1.28 1.13, 1.45 1.20 1.03, 1.39
Girls 1943 1.00 Ref. 1.00 Ref. 1.00 Ref.
Community
Schedule tribe 582 2.89 2.34, 3.58 2.06 1.67, 2.54 2.18 1.70, 2.78
Scheduled caste 1050 1.60 1.33, 1.92 1.48 1.24, 1.77 1.69 1.36, 2.11
Other backward caste 1396 1.36 1.14, 1.62 1.14 0.97, 1.35 1.32 1.07, 1.64
Others 1010 1.00 Ref. 1.00 Ref. 1.00 Ref.
Type of family
Nuclear 1743 1.57 1.36, 1.82 1.35 1.17, 1.55 1.40 1.19, 1.66
Extended nuclear 750 1.20 1.00, 1.44 1.05 0.88, 1.25 1.04 0.83, 1.29
Joint 1545 1.00 Ref. 1.00 Ref. 1.00 Ref.
Mother’s education
Illiterate 1937 2.17 1.80, 2.55 2.10 1.78, 2.48 1.55 1.26, 1.90
1st–8th grade 1194 1.45 1.20, 1.75 1.37 1.14, 1.65 1.37 1.10, 1.71
9th grade or above 907 1.00 Ref. 1.00 Ref. 1.00 Ref.
Per capita income
First tertile (< Rs 500) 1278 2.56 2.18, 3.01 2.15 1.84, 2.51 1.89 1.57, 2.28
Second tertile (Rs 500–1014) 1392 1.60 1.36, 1.88 1.28 1.09, 1.49 1.41 1.17, 1.71
Third tertile ( > Rs 1014) 1368 1.00 Ref. 1.00 Ref. 1.00 Ref.
Source of drinking-water
Tap and tube well 3365 1.00 Ref. 1.00 Ref. 1.00 Ref.
Others 673 0.86 0.72, 1.03 0.86 0.72, 1.02 0.84 0.68, 1.03
Sanitary latrine
Present 1189 1.00 Ref. 1.00 Ref. 1.00 Ref.
Absent 2849 2.38 2.04, 2.77 2.14 1.85, 2.47 1.76 1.47, 2.10
Morbidity
Present 541 0.92 0.76, 1.11 0.85 0.71, 1.03 1.12 0.90, 1.39
Absent 3497 1.00 Ref. 1.00 Ref. 1.00 Ref.

Ref., reference category.

immunized children (53·0 and 63·0 %, respectively) com- communities, respectively, compared with children from
pared with fully immunized children (39·5 and 50·8 %, the others category. The odds of underweight were 2·04
respectively). The underweight and wasting prevalences (95 % CI 1·71, 2·43) times higher among children belong-
were significantly higher (P < 0·001) among 12–35- month- ing to the lowest socio-economic group compared with
old children who did not meet minimum dietary diversity children from the highest socio-economic group. Children
(fewer than four food groups in diet; 54·0 and 31·3 %, from nuclear families had 1·27 (95 % CI 1·09, 1·47) times
respectively) than among children having minimum diet- more risk and children living in kutcha houses had 1·63
ary diversity (39·7 and 19·8 %, respectively). The odds of (95 % CI 1·32, 2·02) times more risk of underweight than
underweight and stunting were 1·7 and 1·6 times higher children from joint families and children living in pucca
among partially/not immunized children compared with houses, respectively. In the second stage, in addition to
children fully immunized against six vaccine-preventable the above variables, mother’s education, sanitary latrine,
diseases, while underweight (OR = 1·65; 95 % CI 1·45, hand-washing practices of mothers, IFA consumption
2·05) and wasting (OR = 1·66; 95 % CI 1·29, 2·12) were during pregnancy, place of birth and birth weight were
higher among children not meeting minimum dietary added. The risk of underweight was 1·48 (95 % CI 1·02,
diversity than among children with minimum dietary 2·14) times higher among children of illiterate mothers
diversity (Table 2). compared with children whose mothers were educated to
9th grade or above. The risk of underweight was 1·37
(95 % CI 1·00, 1·89) times higher among children from HH
Stepwise logistic regression analysis for not having the facility of a sanitary latrine. Low-birth-
undernutrition using the conceptual framework weight children had 2·13 times higher risk of underweight
It was observed that the odds of underweight at entry level (95 % CI 1·43, 3·16) compared with normal-birth-weight
were 2·29 (95 % CI 1·83, 2·86) and 1·40 (95 % CI 1·16, 1·70) children. Furthermore, compared with children whose
times higher among children belonging to ST and SC mothers had consumed ninety or more, underweight risk
IYCF practices and nutritional status 109
Table 2 Bivariate analyses of undernutrition among Indian children aged <3 years, National Nutrition Monitoring Bureau survey, 2011–2012

Underweight Stunting Wasting

Characteristic n OR 95 % CI OR 95 % CI OR 95 % CI
ANC, delivery and IYCF practices
For < 6-month-old children
ANC visits
≥4 321 1.00 Ref. 1.00 Ref. 1.00 Ref.
<4 246 1.56 1.03, 2.35 1.33 0.87, 2.02 1.29 0.87, 1.86
No ANC visits 72 2.90 1.66, 5.07 0.96 0.47, 1.87 3.46 2.02, 5.88
Consumption of IFA tablets
≥ 90 220 1.00 Ref. 1.00 Ref. 1.00 Ref.
< 90 255 2.44 1.51, 3.94 1.40 0.87, 2.25 1.81 1.17, 2.80
Not consumed 162 2.45 1.45, 4.13 1.50 0.89, 2.54 2.92 1.84, 4.64
Type of feeding
BF 492 1.00 Ref. 1.00 Ref. 1.00 Ref.
BF + CF 145 0.67 0.41, 1.07 0.80 0.44, 1.45 0.65 0.38, 1.11
For < 12-month-old children
Place of delivery
Institution 1095 1.00 Ref. 1.00 Ref. 1.00 Ref.
Home 341 1.61 1.24, 2.09 1.41 1.07, 1.85 1.26 0.96, 1.65
Prelacteal feeds given
Yes 367 1.05 0.81, 1.37 1.04 0.79, 1.37 1.25 0.96, 1.62
No 1069 1.00 Ref. 1.00 Ref. 1.00 Ref.
Time of initiation of BF
<1 h 523 1.00 Ref. 1.00 Ref. 1.00 Ref.
1–3 h 507 1.24 0.94, 1.63 1.27 0.95, 1.70 0.92 0.70, 1.22
>3 h 406 1.25 0.94, 1.68 1.34 0.99, 1.82 1.01 0.75, 1.35
Colostrum discarded
Yes 216 1.34 0.98, 1.83 1.15 0.83, 1.60 1.17 0.85, 1.61
No 1220 1.00 Ref. 1.00 Ref. 1.00 Ref.
Birth weight (kg)
≥ 2.5 813 1.00 Ref. 1.00 Ref. 1.00 Ref.
< 2.5 143 2.22 1.52, 3.26 1.74 1.17, 2.58 1.38 0.92, 2.06
Not recorded 480 2.44 1.90, 3.14 1.66 1.28, 2.16 1.92 1.49, 2.46
At 6–11 months
Type of feeding
BF only 136 1.45 1.00, 2.18 1.26 0.85, 1.87 1.69 1.13, 2.51
BF + CF 664 1.00 Ref. 1.00 Ref. 1.00 Ref.
Age at CF initiation (months)
6–8 491 1.00 Ref. 1.00 Ref. 1.00 Ref.
<6 147 0·78 0.52, 1.18 0·66 0.43, 1.02 0·76 0.48, 1.20
>8 25 1.18 0.51, 2.74 1.32 0.58, 3.10 0.74 0.27, 2.03
Not yet started 136 1.38 0.94, 2.05 1.18 0.78, 1.77 1.58 1.05, 2.37
Minimum dietary diversity
Yes 245 1.00 Ref. 1.00 Ref. 1.00 Ref.
No 555 1.20 0.87, 1.67 1.56 1.10, 2.21 1.09 0.77, 1.54

Immunization and feeding practices among 12–35-month-old children

For 12–23-month-old children
Immunization
Fully immunized 1338 1.00 Ref. 1.00 Ref. 1.00 Ref.
Partially/not immunized 143 1.74 1.23, 2.46 1.59 1.11, 2.27 1.20 0.80, 1.81
Age at CF initiation (months)
6–8 1001 1.00 Ref. 1.00 Ref. 1.00 Ref.
<6 295 0.90 0.69, 1.17 0.75 0.57, 0.97 0.86 0.62, 1.20
>8 219 1.19 0.89, 1.61 1.22 0.91, 1.64 1.15 0.81, 1.63
Not yet started 14 5.32 1.47, 19.22 0.88 0.30, 2.55 3.78 1.31, 10.92
Minimum dietary diversity (at 12–35 months)
Yes 2200 1.00 Ref. 1.00 Ref. 1.00 Ref.
No 401 1.65 1.45, 2.05 1.28 1.03, 1.58 1.66 1.29, 2.12

ANC, antenatal care; IYCF, infant and young child; IFA, iron–folic acid; BF, breast-feeding; CF, complementary feeding; ref., reference category.

was 2·14 and 2·09 times higher among those children initiation and morbidity were added, but they were not
whose mothers had consumed fewer than ninety or not observed to be associated with underweight (Table 3).
consumed IFA tablets during pregnancy, respectively. In Similarly, age and gender were associated with stunting.
the third stage, in addition to the above variables, time of The risk of stunting was 1·78 (95 % CI 1·42, 2·23) and 1·44
initiation of breast-feeding, age at complementary feeding (95 % CI 1·19, 1·74) times higher among children
110 II Meshram et al.
Table 3 Adjusted logistic regression analysis of factors associated with undernutrition among Indian children aged <3 years, National
Nutrition Monitoring Bureau survey, 2011–2012

Step 1 Step 2 Step 3

OR 95 % CI OR 95 % CI OR 95 % CI
Underweight using conceptual framework
Gender (ref. = girls)
Boys 1·28 1·13, 1·46 1·31 1·14, 1·49 1·42 1·11, 1·82
Age (ref. = 0–11 months)
12–35 months 1·91 1·66, 2·19 1·96 1·70, 2·26 2·00 1·4, 2·85
Community (ref. = others)
Scheduled tribe 2·29 1·83, 2·86 1·76 1·16, 2·65 1·88 1·24, 2·84
Scheduled caste 1·40 1·16, 1·70 1·27 0·90, 1·83 1·35 0·94, 1·94
Other backward caste 1·35 1·12, 1·61 1·22 0·86, 1·71 1·22 0·86, 1·73
Per capita income (ref. = third tertile)
First tertile 2·04 1·71, 2·43 1·48 1·07, 2·08 1·60 1·15, 2·25
Second tertile 1·40 1·18, 1·66 1·05 0·76, 1·43 1·10 0·80, 1·51
Type of family (ref. = joint)
Nuclear 1·27 1·09, 1·47
Extended nuclear 1·09 0·90, 1·32
Type of house (ref. = pucca)
Kutcha 1·63 1·32, 2·02 1·41 0·94, 2·14
Semi-pucca 1·53 1·27, 1·83 1·39 1·00, 1·94
Sanitary latrine (ref. = present)
Absent 1·37 1·00, 1·89 1·46 1·07, 2·00
Mother’s education (ref. = 9th grade or above)
Illiterate 1·48 1·02, 2·14 1·63 1·14, 2·34
1st–8th grade 1·13 0·76, 1·65 1·22 0·83, 1·79
Birth weight (ref. = ≥ 2·5 kg)
< 2·5 kg 2·13 1·43, 3·16 2·18 1·46, 3·24
Not measured 1·65 1·22, 2·23 1·69 1·28, 2·25
IFA tablets consumed (ref. = ≥ 90)
< 90 2·14 1·31, 3·51 2·27 1·38, 3·73
Not consumed 2·09 1·88, 4·46 2·94 1·90, 4·56

Stunting using conceptual framework

Gender (ref. = girls)
Boys 1·31 1·15, 1·75 1·40 1·10, 1·80 1·44 1·12, 1·85
Age (ref. = 0–11 months)
12–35 months 3·48 3·10, 4·02
Community (ref. = others)
Scheduled tribe 1·78 1·42, 2·23 1·57 1·02, 2·42 1·54 1·01, 2·36
Scheduled caste 1·44 1·19, 1·74 1·46 1·01, 2·12 1·39 0·96, 2·01
Other backward caste 1·17 0·98, 1·40 1·23 0·86, 1·76 1·20 0·84, 1·72
Per capita income (ref. = third tertile)
First tertile 1·91 1·61, 2·28 1·48 1·04, 2·10 1·42 1·01, 2·01
Second tertile 1·21 1·03, 1·42 1·29 0·92, 1·79 1·28 0·92, 1·77
Type of house (ref. = pucca)
Kutcha 1·31 1·08, 1·66
Semi-pucca 1·44 1·21, 1·71
Mother’s education (ref. = 9th grade or above)
Illiterate 1·69 1·17, 2·44 1·59 1·11, 2·30
1st–8th grade 1·17 0·79, 1·73 1·13 0·77, 1·67
Sanitary latrine (ref. = present)
Absent 1·55 1·17, 2·15 1·46 1·06, 2·01
Birth weight (ref. = ≥ 2·5 kg)
< 2·5 kg 1·64 1·09, 2·47 1·61 1·07, 2·43
Not measured 1·17 0·85, 1·61 1·08 0·81, 1·45
IFA tablets consumed (ref. = ≥ 90)
< 90 1·28 0·79, 2·09 1·26 0·77, 2·06
Not consumed 2·08 1·38, 3·13 2·13 1·41, 3·22

Wasting using conceptual framework

Gender (ref. = girls)
Boys 1·22 1·05, 1·45 1·12 0·88, 1·42 1·09 0·86, 1·38
Age (ref. = 0–11 months)
12–35 months 0·62 0·53, 0·72
Community (ref. = others)
Scheduled tribe 1·79 1·39, 2·31
Scheduled caste 1·47 1·18, 1·85
Other backward caste 1·26 1·01, 1·56
IYCF practices and nutritional status 111

Table 3 Continued

Step 1 Step 2 Step 3

OR 95 % CI OR 95 % CI OR 95 % CI
Per capita income (ref. = third tertile)
First tertile 1·52 1·24, 1·85
Second tertile 1·20 0·98, 1·46
Type of house (ref. = pucca)
Kutcha 1·50 1·17, 1·92 1·73 1·16, 2·57 1·90 1·32, 2·75
Semi-pucca 1·29 1·04, 1·59 1·29 0·93, 1·33 1·31 0·97, 1·83
Type of family (ref. = joint)
Nuclear 1·26 1·06, 1·51
Extended nuclear 1·00 0·79, 1·24
Birth weight (ref. = ≥ 2·5 kg)
< 2·5 kg 1·33 0·88, 2·08 1·33 0·88, 2·04
Not measured 1·58 1·16, 2·14 1·75 1·35, 2·27
IFA tablets consumed (ref. = ≥ 90)
< 90 1·60 1·03, 2·50 1·75 1·12, 2·71
Not consumed 1·51 1·03, 2·21 1·64 1·11, 2·40

Ref., reference category; IFA, iron–folic acid tablets.

belonging to ST and SC communities, respectively, com- or consumed fewer than ninety IFA tablets had 1·58, 1·51
pared with children from the others category. The odds of and 1·60 times more risk of wasting, respectively. In the
stunting were 1·91 (95 % CI 1·61, 2·28) times higher among third stage, feeding practices and morbidity was added,
children belonging to the lowest socio-economic group but none of them was significant (Table 3).
than among those from the highest socio-economic group. Regression analysis carried out among 12–23-month-old
Children living in kutcha houses had 1·31 (95 % CI 1·08, children using variables such as education of mother,
1·66) more risk of stunting compared with children living immunization, hand-washing practices before feeding,
in pucca houses. In the second stage, community and per minimum dietary diversity and morbidity during the pre-
capita income, mother’s education, sanitary latrine, birth vious fortnight, keeping age and sex constant, showed that
weight and IFA consumption were significantly associated the risk of undernutrition was significantly higher among
with stunting. The risk of stunting was 1·69 (95 % CI 1·17, children of illiterate mothers, those not receiving any
2·44) times higher among children of illiterate mothers immunization or partially immunized and those not
compared with children whose mothers had studied to 9th meeting minimum dietary diversity (Table 4).
grade or above. The risk of stunting was 1·55 (95 % CI
1·17, 2·15) times higher among children from HH without
a sanitary latrine. Low-birth-weight children had 1·64 times Discussion
higher risk of stunting (95 % CI 1·09, 2·47) than normal-
birth-weight children. Mothers not consuming IFA tablets During 2011–2012, the NNMB carried out for first the time a
increased the children’s risk of stunting by 2·08 (95 % CI study on IYCF practices in ten states of India representing
1·38, 3·13) times compared with consumption of ninety or 80 % of the population. Optimal nutrition in the first 2 years
more IFA tablets during pregnancy. In the third stage, in of life – that is, early and exclusive breast-feeding and
addition to the above variables, infant feeding and mor- continued breast-feeding for 2 years or more, together with
bidity were added, but were not observed to be associated nutritionally adequate, safe, age-appropriate and respon-
with stunting (Table 3). sive complementary feeding starting at 6 months – is critical
Gender was observed to be associated with wasting at to prevent stunting in infancy and early childhood and
entry level. In the first stage, the risk of wasting was 1·79 break the intergenerational cycle of undernutrition. The
(95 % CI 1·39, 2·31) and 1·47 (95 % CI 1·18, 1·85) times present study observed suboptimum IYCF practices among
higher among children belonging to ST and SC commu- the 0–23-month-old children. It was observed that only
nities than among children from the others category. The 36 % of infants received breast-feeding within an hour of
odds of wasting were 1·52 (95 % CI 1·24, 1·85) times higher birth, similar to UNICEF data on this IYCF indicator of 41 %
among children belonging to the lowest socio-economic for India, 43 % for Bangladesh, 50 % for Thailand and
group compared with those from the highest. Children 38 % % in Nigeria. About 50 % of 6–11-month-old children
living in kutcha houses and children from nuclear families were exclusively breast-fed up to 6 months of age, similar to
had 1·50 and 1·26 times more risk of wasting compared the UNICEF findings which showed 57 % of children aged
with their counterparts in pucca houses and joint families. 6–9 months in India were exclusively breast-fed up to
In the second stage, children whose weight was not 6 months, but lower than the findings of 74 % for Bangla-
measured and children whose mothers had not consumed desh and 75 % for Indonesia and Nigeria(16). The National
112 II Meshram et al.
Table 4 Logistic regression analysis of factors associated with undernutrition among Indian children aged 12–23 months, National Nutrition
Monitoring Bureau) survey, 2011–2012

Underweight Stunting Wasting

OR 95 % CI OR 95 % CI OR 95 % CI
Mother’s education (ref. = 9th grade or above)
Illiterate 2·16 1·61, 2·89 2·22 1·69, 2·91 1·65 1·15, 2·36
1st–8th grade 1·63 1·18, 2·24 1·43 1·06, 1·92 1·49 1·01, 2·20
Minimum dietary diversity (ref. = yes)
No 1·39 1·07, 1·81 – – 1·63 1·21, 2·19
Immunization (ref. = fully immunized)
Partially/not immunized 1·54 1·07, 2·21 1·51 1·05, 2·18 – –
Hand-washing practices of mother (ref. = washing before feeding)
Not washing 1·43 1·04, 1·97
Mother is feeding 1·04 0·71, 1·53

Ref., reference category.

Family Health Survey-4 (NFHS-4) also reported similar underweight, stunting and wasting, respectively(17). UNI-
findings for India, which is 55 %(17). Exclusively breast-fed CEF data showed that 35 % of under-5s in South Asia were
infants are at a lower risk of diseases like diarrhoea and stunted, while this prevalence was 34 % in Africa, whereas
pneumonia. In 2011, UNICEF highlighted that breast- wasting prevalence was 16 % in South Asia and 6–9 % in
feeding is a preventive intervention and the most impor- Africa(25).
tant element in reducing child mortality(18). Undernutrition was observed to be significantly higher
WHO recommends that infants should start receiving among children of illiterate mothers, children from SC and
complementary foods at 6 months of age in addition to ST communities, and children from HH of low socio-
breast milk. However, in the present study, only 54 % of economic status. Educated mothers have more efficiency
children aged 6–11 months received complementary in the management of limited HH resources, greater utili-
feeding at 6–7 months of age, which is similar to a pre- zation of health-care services, better health-promoting
vious study(19). NFHS-4 reported only 43 % of children practices, low fertility and more child-centred caring
aged 6–8 months receiving complementary foods(17). practices(26). SC and ST communities are socio-
Undernutrition was observed to be associated with economically deprived groups; children from these com-
antenatal and perinatal care and infant feeding practices. A munities have low socio-economic status and thus high
study by Pokhrel et al.(20) in Nepal observed a significant rates of undernutrition.
association between antenatal care practices and under- High rates of undernutrition may be due to poor knowl-
nutrition among children. Mother’s education was edge of mothers about feeding practices, low education and
observed to be associated with availing of antenatal care poor socio-economic status, similar to other studies(27).
services as observed by Tayie and Lartey(21) and Meshram There is a significant relationship between improvement in
et al.(22). No significant association was observed between nutritional status of children and optimum infant feeding
undernutrition and time of breast-feeding initiation, similar practices by their mothers. Delayed initiation of breast-
to a previous study(19); however, Bahl et al. observed feeding, deprivation from colostrum and improper com-
significant associations between these practices and plementary feeding were significant risk factors for under-
increase in morbidity and mortality among them(23). A nutrition among under-5s as observed by Kumar et al.(28).
significant association between low birth weight and Severe undernutrition was significantly higher in children
undernutrition was observed in the present study, which when weaning was delayed(29). In the present study, the
concurs with our previous studies(19,22). Low-birth-weight prevalence of underweight and stunting was observed to be
babies are more prone to infections and thus under- high among children who received complementary feeding
nutrition. Breast-feeding is the best method of infant after age 8 months compared with children who received
feeding to meet the nutritional, metabolic and psycholo- complementary feeding at 6–8 months of age. It was also
gical needs of the baby. Exclusive breast-feeding is a observed that the prevalence of underweight and stunting
feasible strategy especially in low-income countries as it was higher among partially immunized or not immunized
reduces the risk of infant mortality, morbidity and espe- children than among fully immunized children.
cially infection. Ogbo et al.(24) observed that early initia- The present study found a significant association
tion of breast-feeding was associated with higher maternal between minimum dietary diversity and undernutrition.
education, frequent antenatal care visits and birth interval. Bentley et al.’s study in Mumbai observed that only 13 % of
The prevalence of undernutrition observed in the children aged 6–23 months were meeting minimum diet-
current study is higher except wasting than in the NFHS-4 ary diversity, while 43 % had minimum meal frequency,
carried out in India, which reported 32, 32 and 25 % for but no association was observed with nutritional status(30);
IYCF practices and nutritional status 113
while Arimond and Ruel observed a significant association approved by the Institutional Ethical Committee of the
of dietary diversity with stunting(31). In Ghana, Sakaa et al. National Institute of Nutrition as well as the Scientific
demonstrated that the high percentage of malnutrition in Advisory Committee. Written informed consent was
the children may be attributed to the faulty consistency of obtained from the mothers involved in the study.
foods which are traditionally fed to children as well as to
less emphasis on iron- and vitamin-rich foods(32). Hence
emphasis on providing a variety of food groups to the
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