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Determinants of weaning and its impact on child growth
*Corresponding author: Pradeep Japa, Department of Biochemistry, Government Medical College, Jagitial, Telangana, India. dr.pradeepjapa@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Japa P, Munga DK. Determinants of weaning and its impact on child growth. Wadia J Women Child Health. 2025;4:4-10. doi: 10.25259/WJWCH_52_2024
Abstract
Objectives:
Infancy, a period of rapid physical growth and development, demands good and healthy nutrition apart from breastfeeding. Weaning/complementary feeding is introduced to cater to such high demand at 6 months of age. Several factors play a role in weaning and related practices. This study is directed at analyzing the various factors and their effect on growth and development of the child.
Material and Methods:
A cross-sectional study involving 500 mother–child pairs after obtaining informed consent was initiated. All the mothers consulting the outpatient department were included. Top-fed children were excluded. Mothers were interviewed with a preformed questionnaire about demographic profile, knowledge, practices, source of information on weaning, and factors influencing age of initiation of weaning such as parity, education, occupation, socioeconomic status, sex of the child, religion, and residence. The information collected was analyzed using the Statistical Package for the Social Sciences 20. Results interpreted as mean and standard deviation, percentages, and correlation coefficients. P < 0.05 is considered statistically significant.
Results:
A significant association was found between the age at introduction to weaning and the age of the mother (P = 0.004), weight for age (P = 0.042), and length for age (P = 0.01). A significant negative correlation between the age of initiation of weaning and the weight of the child was established (r = −0.11; P = 0.01). Only 90 mothers started weaning at an appropriate age irrespective of various factors.
Conclusion:
The majority of mothers initiated weaning after 6 months of age. A gap between the knowledge and practices regarding weaning and associated factors exists. Stringent implementation of government-based policies in rural and interior areas, one-on-one assessment at every contact with a healthcare facility, and counseling to the mothers might help develop better weaning practices.
Keywords
Breastfeeding
Growth and development
Weaning
INTRODUCTION
Infancy is a period characterized by rapid physical growth and development. Good and healthy nutrition during this period is vital for ensuring that an infant develops mentally and physically to its fullest potential.[1] It is established that poor infant and young child feeding practices have emerged as major reason for high childhood morbidity and mortality in developing countries.[2] More than 2.4 million child deaths occur in India each year, and two-thirds of these deaths are often related to inappropriate infant feeding practices.[3]
The term weaning means “to accustom to.” Weaning, also known as “complementary feeding,” is the introduction of semisolid or solid food to an infant who is on a liquid diet. When exclusive breastfeeding is no longer sufficient to meet the nutritional demands of the infant, complementary feeding or weaning is started. The change from exclusive breastfeeding to semisolid foods is a very vulnerable period because it is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition and infection in children under 5 years of age worldwide.[4] It has been suggested that in addition to disease prevention strategies, complementary feeding interventions targeting this “critical window” are most efficient in reducing malnutrition and promoting adequate growth and development.[5]
According to the World Health Organization (WHO) guidelines, weaning should be started at 6 months of age in addition to breastmilk, initially 2–3 times a day between 6 and 8 months, increasing to 3–4 times daily between 9 and 11 months and 12 and 24 months, with additional nutritious snacks offered 1–2 times per day, as desired.[6]
The complementary feeding must possess three main characteristics: (i) Timely, i.e., giving food to all infants should be started from 6 months onward; (ii) Adequate, i.e., the complementary foods should be of a nutritional value that can satisfy the growth needs of the child; and (iii) Appropriate, i.e., the foods selected for complementary foods must have variety, be of appropriate texture, and be in sufficient quantity.[7]
Inappropriate complementary feeding practices cause problems such as stunting, delay in motor and mental development, neurological and mental fatigue, frequent diarrhea, lack of micronutrients and macronutrients, or malnutrition.[8]
Knowledge, attitude, and practices that are associated with infant and child feeding form an essential first step towards any intervention program to bring positive behavioral change in the health of the infant.[9] In this context, there needs to be more comprehensive data on weaning practices and their correlation with socioeconomic factors in this region of our country, prompting the initiation of this study.
MATERIAL AND METHODS
A cross-sectional descriptive study was conducted on 500 mothers with children below the age of 24 months attending the outpatient department for immunization or ill health at the district hospital, Ballari, northern part of Karnataka. Mothers of selected children who were willing to participate in the study were interviewed to collect data after obtaining informed consent. Mothers with children of age more than 24 months and top-fed babies since birth due to various reasons were excluded. Institutional ethics committee approval (DHB/DNB/22/2020-21) was obtained before the initiation of the study. Data were collected using a self-administered, pre-designed, semi-structured questionnaire to the mothers regarding the demographic profile, knowledge, practices of weaning, source of information on weaning, and factors influencing age of initiation of weaning like parity (primi or multi gravida), education status of mother (literate or illiterate), occupation (working or housewife), socioeconomic status (Class I–V by Kuppuswamy scale), sex of the child, religion (Hindu, Muslim, others), and residence (urban or rural).
Anthropometric parameters (weight and length) were obtained on children who were included in the study. Weight was measured with minimal clothing and length was measured in a recumbent position. The weight and length measurements were converted into summary indices of nutritional status: Weight-for-age and length-for-age. “Abrupt weaning” defined as sudden change of breastfeeding to semisolid diet, while “Gradual weaning” defined as shift in the feeding over a period of 1 month, as per Indian Academy of Pediatrics were noted.
Information gathered was analyzed using the Statistical Package for the Social Sciences 20 software using the Chi-square test, spearman correlation, and multinomial regression analysis. Results were interpreted through mean ± standard deviation, percentage, and correlation coefficient. P < 0.05 is considered significant.
RESULTS
Five hundred children below 24 months of age and their mothers were included in the study. The baseline demographic data are shown in Table 1. The mean age of the mothers is 26 years and of children is 15 months. Mean age of initiation of weaning is 5.9 months while average weight and length of the children are 8.7 kg and 73.2 cm, respectively.
| Mean | SD | |
|---|---|---|
| Age -child (months) | 15 | 0.25 |
| Age -mother (years) | 26 | 0.23 |
| Length (centimeters) | 73.2 | 0.36 |
| Weight (kilograms) | 8.7 | 0.14 |
| Age at which weaning was initiated (months) | 5.9 | 0.07 |
| Time period in weaning (months) | 14.6 | 0.26 |
SD: Standard deviation
Table 2 shows the distribution of the study group based on various factors. 90 (18%) children were initiated with weaning at the age of 6 months. In this study group, 262 (52.4%) were female and 238 (47.6%) were male children. The gender of the child did not affect the weaning age or practices in our study population. However, only 30 (11.4%) of female children and 33 (13.8%) of male children have been introduced to complementary feeding at 6 months.
| Characteristic | Frequency | Percentage | Percent of children introduced to weaning at 6 months |
|---|---|---|---|
| Sex | |||
| Male | 238 | 47.6 | 17.6 |
| Female | 262 | 52.4 | 14 |
| Literacy | |||
| Illiterate | 129 | 25.8 | 12.3 |
| Literate | 371 | 74.2 | 14.7 |
| Occupation | |||
| Housewife | 203 | 40.6 | 13.7 |
| Working | 297 | 59.4 | 13.8 |
| Socioeconomic status | |||
| Class 1 | 64 | 12.8 | 25 |
| Class 2 | 142 | 28.4 | 12.6 |
| Class 3 | 171 | 34.2 | 12.2 |
| Class 4 | 86 | 17.2 | 12.7 |
| Class 5 | 37 | 7.4 | 2.7 |
| Residence | |||
| Rural | 242 | 48.4 | 11.1 |
| Urban | 258 | 51.6 | 16.2 |
| Religion | |||
| Hindu | 284 | 56.8 | 16.5 |
| Muslim | 187 | 37.4 | 9 |
| Others | 29 | 5.8 | 17.2 |
| Age of initiation of weaning | |||
| <3 months | 24 | 4.8 | |
| 3–4 months | 90 | 18 | |
| 4–5 months | 118 | 23.6 | |
| 5–6 months | 71 | 14.2 | |
| 6–7 months | 90 | 18 | |
| 8–9 months | 87 | 17.4 | |
| >9 months | 20 | 4 | |
| Parity of mother | |||
| Multi | 232 | 46.4 | 12.9 |
| Primi | 268 | 53.6 | 14.5 |
| Source of information | |||
| Advice from health personnel | 167 | 33.4 | 12.5 |
| Family or friends | 148 | 29.6 | 14.8 |
| Literature or media | 110 | 22 | 16.3 |
| Self/Previous experience | 10 | 2 | 10 |
| Others | 65 | 13 | 9 |
| Type of weaning | |||
| Abrupt | 265 | 53 | 14.2 |
| Gradual | 235 | 47 | 13.1 |
| Type of weaning foods | |||
| Commercial and preparation | 229 | 45.8 | 15.6 |
| Homemade | 271 | 54.2 | 12.1 |
This study showed that 371 (74.2%) of the mothers were literate of which only 54 mothers started weaning at 6 months. About 129 (25.8%) were illiterates of which only 17 mothers started weaning at 6 months. No significant statistical difference was noted in the age of initiation of weaning in the infants based on the literacy of the mother.
About 297 (59.4%) of the mothers of children were working and 203 (40.6%) were housewives of our study population. The occupation of the mother did not affect the weaning and associated factors. No statistically significant difference was noted.
In this study, (258) 51.6% of mothers were urban dwellers and (242) 48.4% were from rural Karnataka. The area of residence did not show any significant effect on weaning and associated factors.
171 (34.2%) cases in this study belonged to class 3 of socioeconomic status. Only 24.6% belonged to classes 4 and 5. No significant difference was found between the children belonging to different socioeconomic strata and the age of initiation of weaning.
284 (56.8%) of the cases in this study were Hindus by religion, 187(37.4%) were Muslims, and 29(5.8%) were others. Religious differences did not seem to show any significant differences in weaning and associated characteristics.
This study showed that about 53.6% of the cases were primigravida and 46.4% were multi-gravida with no statistical significance when their weaning habits were compared.
The source of information for 33.4% of the mothers was advice from health personnel, 29.6% of the mothers took weaning-related advice from family/friends, and 22% of the mothers from literature or media. The source of information did not seem to affect various factors of weaning.
This study population reported that about 53.0% of the cases opted for abrupt weaning and 47.0% opted for gradual weaning with no statistical difference between the two groups.
About 45.8% of the mothers opted for commercial preparation for the weaning and 54.2% of them opted for homemade foods. Moreover, commercial or homemade weaning foods did not show any effect when correlated with length and weight eventually, in our study group.
About 59.2% of the normal and 63.5% of the stunted children had weaning between 13 and 24 months. This difference is not statistically significant between the two groups. About 61.5% of the normal and 60.1% of the wasted children had weaning between 13 and 24 months. This difference was not statistically significant between the two groups.
Table 3 shows the results of the comparison between the age of initiation of weaning and various factors associated with it. None of these factors were statistically significant.
| χ2 | P-value | |
|---|---|---|
| Gender | 1.08 | 0.89 |
| Parity | 8.6 | 0.07 |
| Education | 5.08 | 0.27 |
| Occupation | 8.4 | 0.07 |
| Residence | 3.9 | 0.4 |
| Religion | 10.06 | 0.26 |
| Socioeconomic status | 19.9 | 0.22 |
| Weight for age | 7.1 | 0.12 |
| Height for age | 6.18 | 0.18 |
P<0.05 is considered significant
Multinomial regression analysis showed a statistically significant association between the age of initiation of weaning with the age of the mother (P = 0.004), weight of the child (P = 0.042), and length of the child (P = 0.01).
A significant negative correlation between the age of initiation of weaning and the weight of the child was established (r = −0.11; P = 0.01). The correlation between the age of initiation of weaning and length is not statistically significant [Table 4].
| r-value | P-value | |
|---|---|---|
| Age of initiation of weaning vs. Weight | −0.11 | 0.01 |
| Age of initiation of weaning vs. Length | −0.02 | 0.65 |
r-value is Pearson’s correlation coefficient;P<0.05 is considered significant
DISCUSSION
Weaning or complementary feeding is an important aspect of an infant’s nourishment and overall growth. The WHO guidelines suggest that weaning should be started at 6 months of age along with breastfeeding for up to 2 years or more.[6]
Untimely, inadequate, and inappropriate weaning habits may affect the future health of the child. Delayed milestones, lack of weight gain, stunting, and frequent illness are common implications of inappropriate feeding habits. Hence, it is crucial to assess knowledge and weaning habits.
Several factors such as the age of the mother, the age of the child, gender, socioeconomic status (SES), and literacy play important roles in feeding and related aspects.
Age group
The appropriate age to initiate weaning is of paramount importance for normal growth and development of the child. Even though our study population did not show a statistically significant difference when compared to the number of children introduced to weaning in other age groups, it still is a concerning highlight that only 90(18%) children were introduced to weaning at the appropriate age of 6 months according to the WHO guidelines. The rest of the children approximating to 61% were given complimentary feeds either before or after 6 months. Initiating complementary feeding too early or too late may pose multiple risks to the infant. Common effects include gastrointestinal and respiratory tract infections, weight gain during infancy, and obesity in early initiation, while the risk of nutritional insufficiency, immune disorders, and type 1 or 2 diabetes in delayed weaning.[10]
Sex
In a study done in the state of Haryana, the duration of breastfeeding was much shorter for girls than for boys which leads to inadequate nutrition for daughters by weaning them earlier.[11]
In our study, the median age of initiation of weaning and gender predilection for complementary feeding was not seen. However, it is crucial to note that only 17.6% of male and 14% of female children were introduced to weaning at appropriate age. Even though our study group did not exhibit a significant difference based on gender, percentage of children weaned is still rather low according to guidelines.
Literacy
In a community-based study, it was observed that mothers with education status above matriculation had better information and practices about breastfeeding and weaning.[12]
In our observations, the educational status of the mother did not seem to affect the age of initiation to weaning yet only 14.7% literate and 12.3% of illiterate mothers initiated weaning at 6 months.
Occupation
The results of a study in Nigeria showed that occupation and education influenced the frequency and duration of breastfeeding, in addition to the nutritional quality and the type of weaning food fed.[13] However, in our study, a significant influence of education could not be established on weaning practices. 13.8% of working mothers and 13.7% of housewives only weaned their infants at 6 months.
Residence
The findings of a study concluded that early weaning is more common in urban areas than in the rural areas of the western coast of Karnataka. However, we could not establish any statistically significant residence-dependent weaning practices. However, we did notice that a mere 27 (11%) rural and 42 (16%) urban dwellers were initiating weaning at 6 months.[14]
Socio-economic status (SES)
Internationally, studies on the weaning of term infants suggest that mothers who have lower education wean earlier than those with higher education; the results concerning the influence of family income have been equivocal.[15,16]
The encouragement and support of breastfeeding and other healthy feeding practices are especially important for low socioeconomic children who are at increased risk of early childhood obesity status.[17]
In our study group, no statistically significant association was noted between SES and weaning habits. However, a staggeringly low 25%, 12%, 12%, 12%, and 2% of children are introduced to weaning at 6 months from respective socioeconomic classes I–V.
Targeting socioeconomically disadvantaged mothers for breastfeeding support and infant-led feeding strategies may reduce the negative association between SES and child obesity.[17]
Religion
Weaning is a significant event and a rite of passage in many cultures. Cultural and religious perceptions of nursing may influence weaning. However, if more ancient customs collide with the most recent evidence-based weaning recommendations, this could be detrimental to the infant’s growth and development.[18]
In a study done by Ojha et al., in Mysore (Karnataka), 54% of Hindu mothers wean before 12 months, and only 33% of Muslim and 35% of Christian mothers did. A greater proportion of Muslim mothers (58%) wean between 13 and 24 months. Differences again were significant. 66% or more of the mothers in each group practiced gradual weaning rather than forced or casual weaning.[19]
A statistically significant association between religion and weaning practices could not be established in our study population. Only 16% of Hindus, 9% of Muslims, and 17% of other religions initiated weaning at 6 months of age.
Parity
About 14% of primi-gravida mothers in our study started weaning at 6 months, while 12% of multi-gravida mothers introduced complementary feeding at the appropriate age. This difference is not statistically significant. Various studies have shown that the parity of the mother does not influence the age of complementary feeding.[4,20]
Our observations show similar results too. Yet, one must consider that multi-gravida mothers of low socioeconomic strata might face challenges in feeding the children appropriate to their age.
Source of information
With the advent of technology and social media, multiple sources have evolved to provide information on child feeding practices. Healthcare professionals are helpful mentors who offer mothers an evidence-based approach and individualized care by balancing cultural and scientific practices as they wean their children. However, only 33% of mothers in our study population were dependent on healthcare professionals for information on weaning and related aspects of which, only 12.5% initiated weaning at 6 months. On the other hand, 14.8% of mothers relied on family and friends, 16.3% were dependent on literature/media, and 9% had previous experience or others as a source of information and started weaning at the appropriate age. This difference was not statistically significant.
Type of weaning
About 53% of mothers made an abrupt introduction to complimentary food and 47% weaned their children gradually. The type of weaning did not seem to be associated with decreased weight for age or stunting. No statistical significance was noted. The Indian Academy of Pediatrics suggests that breastfeeding should not be stopped abruptly, a gradually weaning from breast milk over one month is the best practice.[21]
Type of weaning food
Conventionally, Indian customs relied heavily on home-made/natural food products, and the usage of commercially available food for infants and toddlers is on the rise. A few reasons include the ease of preparation, storage, convenience, and increased trust in these products. Our study population seems to be more inclined toward home-made food (54.2%) than commercial products (45.8%). The type of weaning food did not seem to show any significant association with weight for age and length for age eventually in our observations. However, it is important to supplement calorie-dense, nutritious weaning food along with other factors such as awareness of baby hunger, identification of satiety cues, and parental feeding habits may all influence the risk of malnutrition.[22]
Age of initiation of weaning and height for age
A study done by Padmadas et al., on 6285 children from six different regions of India revealed that the likelihood of stunting was 77% for children weaned at age >6 months who had not received full immunization in the 1st year and had lived in poor conditions.[23]
We have similar findings in our study, where the age of initiation of weaning is significantly associated with the length of the children eventually (P = 0.01). Complete dependency on breastfeeding alone beyond 6 months could have deleterious nutritional and health implications at later stages of children’s lives.
Age of initiation of weaning and weight for age
A lag in weight gain appropriate for age is probably the earliest sign of malnourishment identified by the mother apart from frequent illness, diarrhea, and lack of age-appropriate milestones. Introduction to complementary feeding has to be done by 6 months of age as there is an increased demand by the rapidly growing child. The delay in weaning and supplying with high energy, nutritious food may lead to low weight for age. In our study, we noticed a significant association between the age of weaning and weight for age (P = 0.042). A negative correlation (r = −0.11) between the age of initiation of weaning and the weight of the child which was statistically significant (P = 0.01) is noted. This indicates that a delayed weaning might result in decreased weight gain for age. Apart from weight gain, late weaning has an independent role in autonomous and psychomotor development in healthy children.[24]
Limitations
As the study group is a random mix of mother–child pairs, it might not exactly point to the origin of the problem. Each mother was interviewed only once hence, the observations might change eventually. A follow-up of the same study population could divulge more information on healthy weaning practices of the region. The calorific and nutritional information of weaning food was not collected.
CONCLUSION
Our observations show a significant association between the age of introduction to weaning and the age of the mother, weight for age, and length for age. Despite multiple programs implemented by the governments and continuing efforts by healthcare professionals, there seems to be a gap in the knowledge and implementation of weaning-related practices in this region of Karnataka. Although most of the factors considered in this study did not show a statistically significant difference, overall, number of children introduced to weaning at 6 months is alarmingly low. Delayed onset of weaning and insufficient knowledge about healthy weaning practices seem to be few factors hindering child healthcare in this study group. Regular workshops, one-on-one counseling at every hospital visit, and increasing the reach of government-laid policies to the interiors of the state might help mitigate the problems associated with weaning practices.
Ethical approval:
The research/study was approved by the Institutional Review Board at District Hospital Bellary, number DHB/DNB/22/2020-21, dated November 25, 2020.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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