INFANT-AND YOUNG CHILD-FEEDING PRACTICES IN MONGOLIA

For almost all infants, breastfeeding remains the simplest, healthiest and least expensive feeding method that fulfils the infants’ needs. To assess the indicators of infant and young child feeding practices among 023 months old children. This cross-sectional studies was conducted all 21 provinces of the 4 economic regions of the country and capital Ulaanbaatar city. A total of 350 children aged 0-23 months were selected from sampled households. In total, 350 children aged less than two years selected through revised 125-cluster sampling using of the indicators for assessing infant and young child feeding (IYCF) practices were revised during the International Consensus Meeting organized be WHO in 2007. The proportions of infants with early initiation of breastfeeding (85.5%) and exclusive breastfeeding at the age of 4-5 months (46.7%) were low and infants who received foods from four and more groups is insufficient in Western and Eastern regions. Consumption of vegetables and fruits was also insufficient. Dairy products (milk, yogurt, cheese and other dairy products) were included in the diet of 75.6% (95%CI 69.2-81.0) of 6-23 month-old children during the previous day (p<0.003). The main problems revealed from the study were inappropriate complementary feeding practices. Our findings have highlighted the need to encourage mothers to enrich their traditional wheatbased complementary foods add more animal source foods and vegetables.


INTRODUCTION
Breast milk is the natural nutrition for all infants.According to the American Academy of Pediatrics (AAP), it is the preferred choice of feeding for all infants 1 .The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life with early initiation and continuation of breastfeeding for two years or more together with nutritionally-adequate, safe, ageappropriate complementary feeding starting at six months 2 .The WHO and United Nations Children Fund have articulated a global strategy for infant-and young child-feeding.Optimal infant-and young child-feeding (IYCF) practices are crucial for nutritional status, growth, development, health, and ultimately the survival of infants and young children [3][4][5] .Worldwide, suboptimal breastfeeding still accounts for deaths of 1.4 million children aged less than five years (under-five mortality).The timely introduction of complementary feeding can prevent almost 6% of underfive mortality6.It was estimated that, if 90% of infants are covered with a package of intervention to protect, promote, and support the optimal IYCF practices, almost one-fifth of overall under-five mortality can be averted 6 .The poor complementary feeding practices mean that many children continue to be vulnerable to irreversible outcomes of stunting, poor cognitive development, and significantly increased risk of infectious diseases, such as diarrhoea and acute respiratory infection 5,7,8 .
The benefits of breastfeeding in reducing the risk of infection and mortality and improving growth in the first 6 months of life have been known for some time 9,10 .
In Mongolia the indicator on exclusive breastfeeding in the first six months of life is only 38.3%, whereas it is 79.7% until 4 months old.The fact that of the children 6-59 months 83.5% were put to the breast within one hour of the birth.The average period of exclusive breastfeeding is 4.87± 2.19 months and the average period of continuous breastfeeding is 19.28 ± 10.63 months 17 .

MATERIALS AND METHODS
The population based, cross-sectional descriptive study was conducted all 21 provinces of the 4 economic regions of the country and capital Ulaanbaatar city among children aged less than two years during July-August 2010 using the two stage revised 125-cluster sampling technique.Trained interviewers collected information on age, sex, and feeding practices of the study children by interviewing mothers/other responsible caregivers at their home.Definitions formulated by the WHO for indicators of the IYCF practices were used 19 .
Analysis of data Survey data was analysed using PASW statistics 18.0 and EPI INFO 2000 software.Frequencies of categorical variables and mean averages of continuous variables were calculated along with 95% confidence interval.For calculation of overall measures for the entire survey sample, analyses were stratified by region.The statistical significance of differences in prevalence and measures of central tendency between subgroups were calculated using, 95% confidence interval and chi-square p value.Ethics The Ethics Committee under the auspices of the Ministry of Health approved the study.

RESULTS: Infant feeding patterns
Although breastfeeding was universal, only 85.5% of the study children were put to the breast within one hour of birth.About 14.5% of the neonates (n=50) had to wait for at least 24 hours for first sips of breast milk.
The proportion of children with early initiation of breastfeeding is statistically significantly higher in Western Region than in Central and Eastern Regions and Ulaanbaatar.The difference between age-groups in the proportion of children having early initiation of breastfeeding, although not significant and sex was not associated with early initiation of breastfeeding is shown in Table 1.
Feeding of 0-5 months old children children aged 0-5 months, 28.7% (95%CI  The percent of children currently breastfeeding at the time of survey data collection was statistically significantly greater in Western Region than in other regions.The prevalence of current breastfeeding in 0-23 month old children was 80.2% (95%CI 73.3-85.6) in rural and 77.5% (95%CI 69.2-84.1) in urban area.

Exclusive breastfeeding:
Overall, 71.3% of the infants aged less than six months were exclusively breastfed.The exclusive breastfeeding rate dropped from 98.0% in infants aged less than two months to 85.8% at 2-3 months and 46.7% at 4-5 months of age in table 3.This decrease in exclusive breastfeeding rates with age was statistically significant.As shown in Figure 1 the prevalence of exclusive breastfeeding in 0-5 month old children was higher in the Central Region (93.3) than in other regions; however, this difference was clearly statistically significant only with the Eastern Region.The proportion of children who were fed at a frequency appropriate for their age was lowest in Eastern Region, intermediate in Western Region, and higher in Ulaanbaatar, Khangai, and Central Regions.The differences between Eastern Region and Central and Khangai Region and Ulaanbaatar were statistically significant (p<0.05)(Figure 2).
Food consumption in children 6-23 months of age: Flesh foods and grains are the dominant complementary foods given to surveyed children, while the consumption of legumes and nuts and eggs was rare (Table 3).As Shown in Table 7, 78.5 percent of children aged 6-23 months who should receive separately cooked meals, were fed with family foods.For this age group children meat and flour porridge, dishes cooked for other household members and yogurt remained the predominant types of complementary food.

Consumption of food rich in vitamin A:
Of the surveyed children aged 0-59 months, 35.5% (95%CI 30.7-40.5)consumed food rich in vitamin A (food rich in vitamin A was defined as carrots, pumpkin, tomato, green pepper, spinach and kiwi).In 6-23 month old children, the proportion was 33.3% (95%CI 26.1-41.5).Consumption of food rich in vitamin A among children aged 6-23 months was higher in Ulaanbaatar and Central Region compared to other regions.The differences between Ulaanbaatar and the other regions were all statistically significant.Only the differences between Central Region and Khangai and Eastern Region and Ulaanbaatar were statistically significant (Table 4).Urban 6-23 month-old children were substantially more likely to receive food rich in vitamin A (44.5%, 95%CI 33.6-56.0)compared to their rural counterparts (16.5%, 95%CI 9.5-27.1).The proportion of children who receive separate meals was highest in Western Region and Ulaanbaatar and lowest in Central Region and Eastern Region.The proportion was statistically significantly higher in Western as compared to Central and Eastern Regions (Figure 3).The practice of cooking separate complementary meals for 6-23 month-old children was found in the caregivers of 76.4% (95%CI 66.1-84.4) of urban children and 60.4% (95%CI 52.9-67.5) of rural children.

DISCUSSION
Early initiation of breastfeeding, exclusive breastfeeding for six months, and timely introduction of age-appropriate complementary feeding are the key interventions to achieve the Millennium Development Goal 1 and 4, which address child malnutrition component of the targets and mortality respectively3.Indicators for Assessing Infant and Young Child Feeding Practices (2007) were revised during the International Consensus Meeting organized by WHO in 2007.The Fourth National Nutrition Survey differs from the previous surveys not only in scope and sampling, but also in using these revised indicators for the assessment of child feeding practices.For this reason, some of the findings of the Fourth National Nutrition Survey could not be compared to previous survey findings.Nutritional indicators estimated using the same methods as in the previous surveys were compared to the latter.
Similarly, findings related to breastfeeding and complementary feeding were compared to the results of MICS survey and Survey on Caregivers' Knowledge, Attitude and Practice Regarding Young Child Feeding (2010) conducted using analogous methods.
The prevalence of early initiation of breastfeeding found in NNS IV is similar to the findings of the previous national nutrition surveys.In 1999, the proportion of newborns put to the breast within 30 minute of the birth was 93.4%.In 2004, 83.5% of newborns were put to the breast within 1 hour of the birth.The prevalence of exclusive breastfeeding in NNS IV demonstrates an increase from the estimate of 57% found in the MICS survey in 2005 conducted by National Statistics Office20.The prevalence rates of continued breastfeeding at 1 and 2 years of age were slightly less than those found in MICS survey (83.2% at 1 year and 64.5% at 2 years).An improvement in

Figure 1 .
Figure 1.Exclusive breastfeeding, by region The percent of 0-5 month old children who were exclusively breastfed was 69.1% (95%CI 50.6-83.0)in urban settings and 74.2% (95%CI 57.7-85.9) in rural settings.Continued breastfeeding at 2 years: Of the surveyed children aged 20-23 months, 54.6% (95%CI 39.6-68.8)were still breastfeeding at the time of survey data collection.Duration of breastfeeding: Median duration of breastfeeding was 14.1 months in 0-59 months old children; 12.8 months in 0-35 months old children.Complementary feeding Complementary feeding frequency of 6-23 month-old children: Of the surveyed children aged 6-23 months, 80.8% (95%CI 73.6-86.3)were fed complementary food at a frequency recommended by WHO.

Figure 2 .
Figure 2. Percent of children aged 6-23 months who are fed at frequency appropriate for their age, by region 70.0% (95%CI 63.2-76.1) of 6-23 month-old children for whom meals need to be cooked separately, receive such complementary feeding.

Table 1 .
Initial breastfeeding practices of study children according to age and sex

Table 2 .
Age appropriate breastfeeding of children aged 0-23 months, by region

Table 3 .
Exclusive breastfeeding, by age groups

Table 7 .
Types of complementary food

Table 8 .
Proportion of children aged 6-23 months whose diet includes food rich in vitamin A, by region