Infant and child feeding index
http://www.100md.com
《美国医学杂志》
Department of Foods and Nutrition, The M.S. University of Baroda, Vadodara, Gujrat, India
Abstract
Traditional indicators of child feeding practices are widely used and appear to be useful, although the validity and reliability of those related to complementary feeding have not been established. Composite child feeding indices have the potential to address some of the methodological constraints related to the quantitative measurement of child feeding practices. They can address the multi-dimensionality of child feeding practices i.e. the need to consider the type, quality, texture, nutrient density of food, frequency of feeding and diversity of the diet; the age-specificity of child feeding practices; and the fact that feeding practices tend to cluster. The main advantage of creating a composite index is that it allows construction of one variable representing various dimensions of feeding or care practices. This variable, in turn, can be used to illustrate graphically the importance of child feeding or care for child outcomes or to model their determinants. This can be invaluable for advocacy, apart from being an indispensable tool for the purposes of research, monitoring and evaluation. Experience with creation of composite child feeding indices with the studies in Accra and DHS data sets from Latin America and Ethiopia has been encouraging and suggests that this is a promising area for future development and program applications.
Keywords: Indicators; Infant and young child feeding; Composite index
With less than a decade to go until the deadline for achieving the Millennium Development Goals (MDGs), it is clear that the key targets for health and nutrition agreed by heads of states in 2000 are likely to be missed.[1] Childhood under nutrition continues to be a major public health problem throughout the developing world and is one of the principal underlying causes of death and disease in many children of the world.[1], [2], [3]
Nutrition interventions have been suggested to be among the most effective preventive actions for reducing under-five mortality in the developing world. It is estimated that among children living in forty-two countries with 90% of global deaths, a package of effective nutrition interventions including promotion of exclusive and continued breast feeding, complementary feeding, vitamin A and zinc supplementation have the potential to save 25% of childhood deaths each year.[4]
Adequate nutrition through appropriate infant and young child feeding (IYCF) during infancy and early childhood is fundamental to the development of each child's full human potential. However, it is disheartening to note that the critical IYCF practices are faulty around the world, with the literature suggesting that only 37% of infants are exclusively breast fed for the first six months and only 55% are introduced to complementary food with continued breastfeeding in the age group of 6-9 months. Only half of the world's children are breast fed at the age of 20-23 months.[5]
Instruments for measuring IYCF - Methodological Considerations
One of the prerequisites for development of successful interventions to improve child nutrition is the availability of appropriate instruments to assess current feeding practices and monitor the impact of programs designed to improve them. Although indicators describing optimal breastfeeding (BF) practices have been available and have been in use for some time,[6] consistent and reliable indicators for optimal or adequate complementary feeding (CF) have been lacking,[7] Lack of valid indicators and absence of clear cut international guidelines on certain key issues have, to some extent, been held responsible for lack of dedicated scientific efforts and dismal improvement in IYCF, especially CF practices around the world.[7] A variety of researches are conducted the world over, utilizing varied and indigenous indicators for measuring the CF practices. This has resulted in creation of a large albeit heterogeneous and to some extent inconclusive databank. While IYCF is the most widely researched topic of public health importance, issues regarding detailed measurement of CF practices still need to be sorted out. This may pay rich dividends in terms of development of relevant interventions and programs focusing on the key issues highlighted by well researched indicators of complementary feeding.
The methodological constraints in creation and use of indicators measuring complementary feeding practices are as following:
1. Feeding Practices are Multidimensional : Child feeding, which includes breastfeeding and complementary feeding practices, is comprised of various dimensions, namely, the type, the quality, the texture, the nutrient density, the frequency of feeding, and the diversity of the diet. Also lately the safety of food fed and the manner in which it is fed to the child are added dimensions to the whole spectrum of IYCF.[8] These various dimensions are difficult to combine into one indicator and thus, most research on feeding practices has focused on only one or two dimensions at a time. This has resulted in fragmented information, and has prevented progress in understanding the association between overall feeding patterns (as opposed to one single feeding practice) and child health and nutrition outcomes. Most research on the relationship between IYCF practices and health outcomes till date has focused on single behaviors, e.g. exclusive breastfeeding,[9],[10],[11] timing of introduction of complementary foods,[12] and the importance of animal products in complementary feeding.[13] These approaches, while valuable for evaluating the role of individual practices, do not allow an examination of the impact of child feeding practices as a whole on children's health and nutrition outcomes.
2. Feeding Practices are Age-Specific : Appropriate child feeding practices are age-specific, and they are also defined within very narrow age ranges. They follow a continuum from exclusive breastfeeding, starting soon after birth, to the complete adaptation of the child to the family diet. As seen in Figure1, exclusive breastfeeding is the key feeding practice of concern up to 6 months of age, but after this age indicators reflecting the use of complementary foods (quality, quantity and frequency) must be included in any evaluation of IYCF. Thus, in order to characterize the adequacy of child feeding practices, one needs to take into account the various dimensions of child feeding, as well as the age-specific requirements of the child within short time periods.
3. Feeding Practices are likely to Cluster : It is possible that child-feeding practices also cluster. That is, it is likely that a mother who initiates breastfeeding at birth and who exclusively breastfeeds for 6 months will also be more aware of (or more likely to seek expert information about) recommended optimal complementary feeding.
Experience in Creation and Utility of IYCF Indices
Child feeding indices have the potential to address some of the above-mentioned concerns related to the analysis and interpretation of child feeding patterns. Indices combine various dimensions of the concept studied into one variable, which can then be used to quantify relationships. In the case of childcare and feeding practices, the use of indices allows researchers either to quantify the importance of these combined practices for child nutrition and health outcomes, or to look globally at the main constraints to good practices. In addition, because of the possibility of making the various components of the index age-specific, use of this method allows the analysis to be carried out over a wide age-range.
The following section presents some of the recent research endeavors in the direction of creation of child feeding indices to concisely represent the IYCF practices, and to study its association with child outcomes.
A composite childcare index was created in a study in Accra,[14] which included three dimensions of care: (i) traditional child feeding practices - breastfeeding, use of prelacteal feedings, and timing of introduction of complementary liquids and foods in the child's diet; (ii) caregiver-child interactions-who helped the child eat and how the caregiver responded to the child's refusal to eat, and; (iii) preventive health seeking behaviors- attendance at growth monitoring and whether the child had been immunized. This index proved to be a very useful tool for examining associations between childcare and nutritional status. It allowed the researchers to look not only at bivariate relationships, but also consider the importance of care for nutrition in multivariate models that controlled for other known child, maternal, and household determinants. In addition, the index allowed summarizing the information into simple, insightful and easily interpretable graphical representations which could be particularly useful for advocacy.
In a follow up analysis of this study,[15] the care index was split into two separate indices: (i) a child feeding index, which included both the traditional child feeding and the feeding style variables; and (ii) a preventive health seeking behavior index, in order to look at the constraints to childcare practices and to determine whether the constraints were the same for child feeding, health seeking and hygiene. The findings showed both differences and similarities in the constraints to good care practices between dimensions. Low maternal education was consistently associated with poorer practices in all three dimensions, whereas socio-economic factors only affected practices related to hygiene. The results highlight that the two approaches to using indices provide different insights and that the purpose of the analysis should guide the type of index used.
The DHS surveys are widely available nationally representative data sets and constitute the richest sources of information on child feeding and nutrition currently available for most countries.[16] Using these datasets from five Latin American countries,[17] a child feeding index was created including the dimensions of breastfeeding practices, dietary diversity, food frequency, and meal frequency. Results showed a significant association between the index and child nutritional status, reflected in HAZ. Differences as large as 0.9 to 1.5 Z-scores were observed between the lowest and highest feeding terciles. These findings were confirmed by multivariate analyses that controlled for child, maternal and family characteristics. Interesting country-specific interactions were also identified between the child feeding index terciles and specific maternal and socio-economic characteristics. These efforts were also useful in identifying subgroups for which the association with child nutrition was larger, and who, therefore, would be more likely to benefit from interventions.
Another age-specific infant/child feeding index (CFI) was created from DHS datasets from Ethiopia,[18] which included five components- a breastfeeding score, a bottle use score, a 24-hour dietary diversity score, a score for frequency of feeding solids/semi-solid foods in the previous 24-hours and, a 7-day quasi-food group frequency score. This child feeding index (CFI) was found to be associated with child nutritional status, especially height-for-age, in bivariate analyses as well as multivariate analyses.
In India, to our knowledge no attempt has been made in this direction, although the NFHS-2 dataset does provide child feeding information, albeit not in the required details, to be able to take up a dedicated research initiative. One such study has been taken up by the authors in which a number of IYCF indicators were measured from which five key indicators, demonstrating significant impact on HAZ were selected, scored, weighted and summed to compose an infant and child feeding index. Preliminary results of this research has revealed that the index was significantly related to nutritional status of children, especially HAZ, and to critical maternal characteristics like education and body mass index. The index offered an improved way of presentation and analysis of child feeding as one holistic indicator.[19]
Conclusion
Experience with constructing a child-feeding index has so far been successful. The main advantage of creating a composite index is that it allows construction of one variable representing various dimensions of feeding or care practices. This variable, in turn, can be used to illustrate graphically the importance of child feeding or care for child outcomes or to model their determinants. This can be invaluable for advocacy. In addition, these indices also allow the identification of vulnerable groups and thus can be used for targeting interventions. Although attempts have been successful in achieving their own research objectives, a single globally acceptable and applicable IYCF index composed of critical parameters with scientifically established cut offs is needed. Research endeavours need to be made towards the development of such an index which can then be simplified for programmatic and advocacy purposes.
References
1. Fifth Report on the World Nutrition Situation. Nutrition for improved Developmental Outcomes. UN Standing Committee on Nutrition, SCN, Geneva, 2004.
2. Murray C, Lopez A. Global mortality, disability and the contribution of risk factors: Global burden of disease study. Lancet 1997; 349: 1436-1442.
3. Murray C, Lopez A. Mortality by cause for eight regions of the world: Global burden of disease study. Lancet 1997; 349: 1269-1276.
4. Jones G. How many child deaths can we prevent this year Lancet 2003; 362 : 65-71.
5. UNICEF. The State of the World's Children. UNICEF, New York, 2005
6. World Health Organization. Indicators for assessing breast-feeding practices. Reprinted report of an informal meeting 11-12 June 1991, Geneva.WHO/CDD/SER/91.14. Geneva.
7. Piwoz EG, Huffman SL, Quinn VJ. Promotion and Advocacy for Improved Complementary Feeding: Can We Apply the Lessons Learned from Breastfeeding Food and Nutrition Bulletin 2003; 24 (1) : 29-44.
8. PAHO/WHO. Guiding principles for complementary feeding of the breastfed child Washington DC: PAHO, WHO; 2003
9. Popkin BM, Adair l, Akin JS, Black R, Briscoe J , Flieger W. Breastfeeding and diarrhoeal morbidity. Pediatrics 1990; 86: 874-882.
10. Victoria CG, Smith PG, Vaughan JP et al. Infant feeding and deaths due to diarrhea. A case-control study. American Journal of Epidemiology 1989; 129: 1032-1041.
11. Brown LV, Zeitlin MF, Peterson KE et al. Evaluation of the impact of weaning food messages on infant feeding practices and child growth in rural Bangladesh. American Journal of Clinical Nutrition 1992; 56: 994-1003.
12. Bhandari N, Mazumder S, Bahl R. An educational intervention to promote appropriate complementary feeding practices and physical growth in infants and young children in rural Haryana, India. J Nutr 2004; 134 : 2342-2348.
13. Marquis GS, Habicht SP, Lanata CF, Black RE, Ramussen KM. Breast milk or animal products improve linear growth of Peruvian toddlers consuming marginal diets. American Journal of Clinical Nutrition 1997; 66: 1102-1109.
14. Ruel, M, Levin, CE, Armar-Klemesu M., Maxwell DG, Morris SS. Good care practices mitigate the negative effects of poverty and low maternal schooling on children's nutritional status: evidence from Accra. World Development 1999 ; 27: 1993-2009.
15. Armar-Klemesu M, Ruel M, Maxwell D, Levin C, Morris S. Poor maternal schooling is the main constraint to good childcare practices in Accra. J Nutr 2000; 130: 1597-1607.
16. Demographic and Health Surveys. ORC Macro, 2003. Measure DHS+ STATcompiler. http://www.measuredhs.com
17. Ruel MT, Menon P. Child feeding practices are associated with child nutritional status in Latin America: innovative use of the Demographic Health Surveys. J Nutr 2002; 132 : 1180-1187.
18. Arimond M, Ruel M. Summary indicators for infant and child feeding practices: an example from the Ethiopia Demographic and Health Survey 2000. FANTA, AED Washington DC; 2002
19. Srivastava N, Sandhu A. Utility Of Constructing An Infant And Child Feeding Index - A Research, Monitoring, Evaluation And Advocacy Tool. M.Sc Dissertation, Department of Foods and Nutrition, M.S. University of Baroda, Vadodara, 2005 (unpublished)(Srivastava N, Sandhu A)
Abstract
Traditional indicators of child feeding practices are widely used and appear to be useful, although the validity and reliability of those related to complementary feeding have not been established. Composite child feeding indices have the potential to address some of the methodological constraints related to the quantitative measurement of child feeding practices. They can address the multi-dimensionality of child feeding practices i.e. the need to consider the type, quality, texture, nutrient density of food, frequency of feeding and diversity of the diet; the age-specificity of child feeding practices; and the fact that feeding practices tend to cluster. The main advantage of creating a composite index is that it allows construction of one variable representing various dimensions of feeding or care practices. This variable, in turn, can be used to illustrate graphically the importance of child feeding or care for child outcomes or to model their determinants. This can be invaluable for advocacy, apart from being an indispensable tool for the purposes of research, monitoring and evaluation. Experience with creation of composite child feeding indices with the studies in Accra and DHS data sets from Latin America and Ethiopia has been encouraging and suggests that this is a promising area for future development and program applications.
Keywords: Indicators; Infant and young child feeding; Composite index
With less than a decade to go until the deadline for achieving the Millennium Development Goals (MDGs), it is clear that the key targets for health and nutrition agreed by heads of states in 2000 are likely to be missed.[1] Childhood under nutrition continues to be a major public health problem throughout the developing world and is one of the principal underlying causes of death and disease in many children of the world.[1], [2], [3]
Nutrition interventions have been suggested to be among the most effective preventive actions for reducing under-five mortality in the developing world. It is estimated that among children living in forty-two countries with 90% of global deaths, a package of effective nutrition interventions including promotion of exclusive and continued breast feeding, complementary feeding, vitamin A and zinc supplementation have the potential to save 25% of childhood deaths each year.[4]
Adequate nutrition through appropriate infant and young child feeding (IYCF) during infancy and early childhood is fundamental to the development of each child's full human potential. However, it is disheartening to note that the critical IYCF practices are faulty around the world, with the literature suggesting that only 37% of infants are exclusively breast fed for the first six months and only 55% are introduced to complementary food with continued breastfeeding in the age group of 6-9 months. Only half of the world's children are breast fed at the age of 20-23 months.[5]
Instruments for measuring IYCF - Methodological Considerations
One of the prerequisites for development of successful interventions to improve child nutrition is the availability of appropriate instruments to assess current feeding practices and monitor the impact of programs designed to improve them. Although indicators describing optimal breastfeeding (BF) practices have been available and have been in use for some time,[6] consistent and reliable indicators for optimal or adequate complementary feeding (CF) have been lacking,[7] Lack of valid indicators and absence of clear cut international guidelines on certain key issues have, to some extent, been held responsible for lack of dedicated scientific efforts and dismal improvement in IYCF, especially CF practices around the world.[7] A variety of researches are conducted the world over, utilizing varied and indigenous indicators for measuring the CF practices. This has resulted in creation of a large albeit heterogeneous and to some extent inconclusive databank. While IYCF is the most widely researched topic of public health importance, issues regarding detailed measurement of CF practices still need to be sorted out. This may pay rich dividends in terms of development of relevant interventions and programs focusing on the key issues highlighted by well researched indicators of complementary feeding.
The methodological constraints in creation and use of indicators measuring complementary feeding practices are as following:
1. Feeding Practices are Multidimensional : Child feeding, which includes breastfeeding and complementary feeding practices, is comprised of various dimensions, namely, the type, the quality, the texture, the nutrient density, the frequency of feeding, and the diversity of the diet. Also lately the safety of food fed and the manner in which it is fed to the child are added dimensions to the whole spectrum of IYCF.[8] These various dimensions are difficult to combine into one indicator and thus, most research on feeding practices has focused on only one or two dimensions at a time. This has resulted in fragmented information, and has prevented progress in understanding the association between overall feeding patterns (as opposed to one single feeding practice) and child health and nutrition outcomes. Most research on the relationship between IYCF practices and health outcomes till date has focused on single behaviors, e.g. exclusive breastfeeding,[9],[10],[11] timing of introduction of complementary foods,[12] and the importance of animal products in complementary feeding.[13] These approaches, while valuable for evaluating the role of individual practices, do not allow an examination of the impact of child feeding practices as a whole on children's health and nutrition outcomes.
2. Feeding Practices are Age-Specific : Appropriate child feeding practices are age-specific, and they are also defined within very narrow age ranges. They follow a continuum from exclusive breastfeeding, starting soon after birth, to the complete adaptation of the child to the family diet. As seen in Figure1, exclusive breastfeeding is the key feeding practice of concern up to 6 months of age, but after this age indicators reflecting the use of complementary foods (quality, quantity and frequency) must be included in any evaluation of IYCF. Thus, in order to characterize the adequacy of child feeding practices, one needs to take into account the various dimensions of child feeding, as well as the age-specific requirements of the child within short time periods.
3. Feeding Practices are likely to Cluster : It is possible that child-feeding practices also cluster. That is, it is likely that a mother who initiates breastfeeding at birth and who exclusively breastfeeds for 6 months will also be more aware of (or more likely to seek expert information about) recommended optimal complementary feeding.
Experience in Creation and Utility of IYCF Indices
Child feeding indices have the potential to address some of the above-mentioned concerns related to the analysis and interpretation of child feeding patterns. Indices combine various dimensions of the concept studied into one variable, which can then be used to quantify relationships. In the case of childcare and feeding practices, the use of indices allows researchers either to quantify the importance of these combined practices for child nutrition and health outcomes, or to look globally at the main constraints to good practices. In addition, because of the possibility of making the various components of the index age-specific, use of this method allows the analysis to be carried out over a wide age-range.
The following section presents some of the recent research endeavors in the direction of creation of child feeding indices to concisely represent the IYCF practices, and to study its association with child outcomes.
A composite childcare index was created in a study in Accra,[14] which included three dimensions of care: (i) traditional child feeding practices - breastfeeding, use of prelacteal feedings, and timing of introduction of complementary liquids and foods in the child's diet; (ii) caregiver-child interactions-who helped the child eat and how the caregiver responded to the child's refusal to eat, and; (iii) preventive health seeking behaviors- attendance at growth monitoring and whether the child had been immunized. This index proved to be a very useful tool for examining associations between childcare and nutritional status. It allowed the researchers to look not only at bivariate relationships, but also consider the importance of care for nutrition in multivariate models that controlled for other known child, maternal, and household determinants. In addition, the index allowed summarizing the information into simple, insightful and easily interpretable graphical representations which could be particularly useful for advocacy.
In a follow up analysis of this study,[15] the care index was split into two separate indices: (i) a child feeding index, which included both the traditional child feeding and the feeding style variables; and (ii) a preventive health seeking behavior index, in order to look at the constraints to childcare practices and to determine whether the constraints were the same for child feeding, health seeking and hygiene. The findings showed both differences and similarities in the constraints to good care practices between dimensions. Low maternal education was consistently associated with poorer practices in all three dimensions, whereas socio-economic factors only affected practices related to hygiene. The results highlight that the two approaches to using indices provide different insights and that the purpose of the analysis should guide the type of index used.
The DHS surveys are widely available nationally representative data sets and constitute the richest sources of information on child feeding and nutrition currently available for most countries.[16] Using these datasets from five Latin American countries,[17] a child feeding index was created including the dimensions of breastfeeding practices, dietary diversity, food frequency, and meal frequency. Results showed a significant association between the index and child nutritional status, reflected in HAZ. Differences as large as 0.9 to 1.5 Z-scores were observed between the lowest and highest feeding terciles. These findings were confirmed by multivariate analyses that controlled for child, maternal and family characteristics. Interesting country-specific interactions were also identified between the child feeding index terciles and specific maternal and socio-economic characteristics. These efforts were also useful in identifying subgroups for which the association with child nutrition was larger, and who, therefore, would be more likely to benefit from interventions.
Another age-specific infant/child feeding index (CFI) was created from DHS datasets from Ethiopia,[18] which included five components- a breastfeeding score, a bottle use score, a 24-hour dietary diversity score, a score for frequency of feeding solids/semi-solid foods in the previous 24-hours and, a 7-day quasi-food group frequency score. This child feeding index (CFI) was found to be associated with child nutritional status, especially height-for-age, in bivariate analyses as well as multivariate analyses.
In India, to our knowledge no attempt has been made in this direction, although the NFHS-2 dataset does provide child feeding information, albeit not in the required details, to be able to take up a dedicated research initiative. One such study has been taken up by the authors in which a number of IYCF indicators were measured from which five key indicators, demonstrating significant impact on HAZ were selected, scored, weighted and summed to compose an infant and child feeding index. Preliminary results of this research has revealed that the index was significantly related to nutritional status of children, especially HAZ, and to critical maternal characteristics like education and body mass index. The index offered an improved way of presentation and analysis of child feeding as one holistic indicator.[19]
Conclusion
Experience with constructing a child-feeding index has so far been successful. The main advantage of creating a composite index is that it allows construction of one variable representing various dimensions of feeding or care practices. This variable, in turn, can be used to illustrate graphically the importance of child feeding or care for child outcomes or to model their determinants. This can be invaluable for advocacy. In addition, these indices also allow the identification of vulnerable groups and thus can be used for targeting interventions. Although attempts have been successful in achieving their own research objectives, a single globally acceptable and applicable IYCF index composed of critical parameters with scientifically established cut offs is needed. Research endeavours need to be made towards the development of such an index which can then be simplified for programmatic and advocacy purposes.
References
1. Fifth Report on the World Nutrition Situation. Nutrition for improved Developmental Outcomes. UN Standing Committee on Nutrition, SCN, Geneva, 2004.
2. Murray C, Lopez A. Global mortality, disability and the contribution of risk factors: Global burden of disease study. Lancet 1997; 349: 1436-1442.
3. Murray C, Lopez A. Mortality by cause for eight regions of the world: Global burden of disease study. Lancet 1997; 349: 1269-1276.
4. Jones G. How many child deaths can we prevent this year Lancet 2003; 362 : 65-71.
5. UNICEF. The State of the World's Children. UNICEF, New York, 2005
6. World Health Organization. Indicators for assessing breast-feeding practices. Reprinted report of an informal meeting 11-12 June 1991, Geneva.WHO/CDD/SER/91.14. Geneva.
7. Piwoz EG, Huffman SL, Quinn VJ. Promotion and Advocacy for Improved Complementary Feeding: Can We Apply the Lessons Learned from Breastfeeding Food and Nutrition Bulletin 2003; 24 (1) : 29-44.
8. PAHO/WHO. Guiding principles for complementary feeding of the breastfed child Washington DC: PAHO, WHO; 2003
9. Popkin BM, Adair l, Akin JS, Black R, Briscoe J , Flieger W. Breastfeeding and diarrhoeal morbidity. Pediatrics 1990; 86: 874-882.
10. Victoria CG, Smith PG, Vaughan JP et al. Infant feeding and deaths due to diarrhea. A case-control study. American Journal of Epidemiology 1989; 129: 1032-1041.
11. Brown LV, Zeitlin MF, Peterson KE et al. Evaluation of the impact of weaning food messages on infant feeding practices and child growth in rural Bangladesh. American Journal of Clinical Nutrition 1992; 56: 994-1003.
12. Bhandari N, Mazumder S, Bahl R. An educational intervention to promote appropriate complementary feeding practices and physical growth in infants and young children in rural Haryana, India. J Nutr 2004; 134 : 2342-2348.
13. Marquis GS, Habicht SP, Lanata CF, Black RE, Ramussen KM. Breast milk or animal products improve linear growth of Peruvian toddlers consuming marginal diets. American Journal of Clinical Nutrition 1997; 66: 1102-1109.
14. Ruel, M, Levin, CE, Armar-Klemesu M., Maxwell DG, Morris SS. Good care practices mitigate the negative effects of poverty and low maternal schooling on children's nutritional status: evidence from Accra. World Development 1999 ; 27: 1993-2009.
15. Armar-Klemesu M, Ruel M, Maxwell D, Levin C, Morris S. Poor maternal schooling is the main constraint to good childcare practices in Accra. J Nutr 2000; 130: 1597-1607.
16. Demographic and Health Surveys. ORC Macro, 2003. Measure DHS+ STATcompiler. http://www.measuredhs.com
17. Ruel MT, Menon P. Child feeding practices are associated with child nutritional status in Latin America: innovative use of the Demographic Health Surveys. J Nutr 2002; 132 : 1180-1187.
18. Arimond M, Ruel M. Summary indicators for infant and child feeding practices: an example from the Ethiopia Demographic and Health Survey 2000. FANTA, AED Washington DC; 2002
19. Srivastava N, Sandhu A. Utility Of Constructing An Infant And Child Feeding Index - A Research, Monitoring, Evaluation And Advocacy Tool. M.Sc Dissertation, Department of Foods and Nutrition, M.S. University of Baroda, Vadodara, 2005 (unpublished)(Srivastava N, Sandhu A)