Multiple factors influence why mothers do not exclusively breastfeed, including beliefs and cultural norms [21]. Mothers encounter multiple challenges that discourage exclusive breastfeeding through 6 months of age. Prenatally, women who lack access to breastfeeding information and education are less likely to initiate after birth [22]. During labor, both the maternal labor experience and the breastfeeding attitudes of the hospital staff can impact the maternal breastfeeding intention, which is associated with early weaning [23]. In the postpartum period, women who have clinical problems, such as low supply or problems with infant latch, are more likely to discontinue breastfeeding. Women who identify a lack of clinical/provider support are more likely to discontinue breastfeeding before 6 months. Also, women who return to work before 6 months are less likely to be exclusively breastfeeding for 6 months [24-26].
Complementary Feeding
As noted above, the guidelines recommend exclusive breastfeeding until infants are 6 months of age with the gradual introduction of nutritionally safe and adequate complementary foods [6]. To measure adequacy of CF, the WHO indicators defined above are used: MDD, MMF, and MAD [16]. Dietary diversity reflects a nutritionally adequate diet. Children aged 6–23 months should eat food from at least 4 of the following food groups a day: grains, roots and tubers, legumes and nuts, dairy products, meat and fish, eggs, Vitamin A-rich fruits and vegetables, and other fruits and vegetables. A diet lacking in diversity can increase a child’s risk of micronutrient deficiencies [7]. Yet, only 29% of the world’s children meet the requirements [27]. Additionally, children need to eat frequently throughout the day to meet their energy and nutrient requirements. However, only 50% of young children (6–23 months) are meeting the MMF requirements. Among children under 2 years old, there is an equity gap between rich and poor for both MDD and MMF [7]. Globally, children from poorer households consume less diverse and more infrequent meals compared to those from richer households. Low maternal education levels and maternal media exposure were also associated with suboptimal CF practices in multiple countries [28-33].
Within India, the only CF indicator evaluated in both the 2005–2006 and the 2015–2016 national surveys was the percent of children aged 6–8 months receiving solid or semi-solid food and breastmilk [19, 20]. The percent of children who received solid or semi-solid food and breastmilk decreased by 10%, despite data that showed the breastfeeding indicators substantially increased during this period (Table 1) [19, 20]. While the reasons for this decrease are not clear, CF programs and policies should be strengthened as part of infant and young child nutrition (IYCN) programs.
Accompanying the nutrition transition, multinational beverage companies and their products are more accessible worldwide [34]. Global data on child beverage consumption is extremely limited, especially among children under 2 years old. Most of the literature is specific to the United States and results from the Feeding Infants and Toddlers Study [35]. From the Feeding Infants and Toddlers Study data, Kay et al. [35] found that breastmilk and formula were the top 2 beverages consumed among children younger than 12 months, and as expected, cow’s milk consumption continued to increase as children aged. Children older than 12 months had an average 100% juice consumption of 8 ounces per day, almost twice the recommended amount [35, 36].
Beverage data are limited within India as well. An analysis of the 2005–2006 Indian National Family Health Survey showed that nearly 10% of children (ages 6–59 months) had not consumed any water in the last 24 h [37]. Of those children, over 50% reported not drinking any beverages, while a quarter reported drinking 2 or more beverages such as tea, coffee, or juice. Children over 2 years old were more likely to consume non-milk beverages compared to younger children. The authors found in settings where water is scarce, sugar-sweetened beverages, such as juice or soda, are more widely consumed among younger children [37]. More global data on beverage consumption during early childhood are needed to track sugar-sweetened beverage consumption and its impact on growth throughout early childhood.
Caregiver Feeding Styles
Not only do caregivers play a prominent role in what and when children are fed, they also determine how children are fed. Parental feeding styles play a significant role in establishing healthy behaviors for optimal growth and development [38]. The WHO recommends that parents and caregivers practice RF [14]. According to Black and Aboud RF, includes “(1) ensuring that the feeding context is pleasant with few distractions; (2) encouraging and attending to the child’s signals of hunger and satiety; and (3) responding to the child in a prompt, emotionally supportive, contingent, and developmentally appropriate manner” [15]. Non-RF is defined as “A lack of reciprocity between the parent and child, with the caregiver taking excessive control of the feeding situation (pressuring or restricting food intake), the child completely controlling the feeding situation (indulgent), or the caregiver being uninvolved during meals (laissez faire)” [39]. The importance of the dyadic relationship and the role of infant temperament play a role in how caregiver feeding style may be influenced. For example, caregivers who perceive infants to be “fussy” or “active” may introduce complementary foods more often, as a way to sooth a crying or an active infant [40,