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A global perspective on improving the diets of infants and young children

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Grainne Moloney is Senior Nutrition Advisor at UNICEF headquarters, New York

Linda Shaker Berbari is Nutrition Specialist at UNICEF headquarters, New York

Harmonie Bucher is Nutrition Officer at UNICEF headquarters, New York

Dear readers,

Together with colleagues from ENN, we are delighted to present this special section of Field Exchange (FEX) focusing on complementary feeding programming in fragile and emergency contexts. Our aim is to provide you with an array of experiences from multiple contexts documenting actions for improving the diets of young children. The section provides a snapshot of recent developments related to complementary feeding, involving research, experiences and guidance development. It also includes an overview of the latest UNICEF actions at the global, regional and country level to support complementary feeding in fragile settings.  As well as the publications here in print, additional articles from the series are available online here.

We have made the decision to support this special section as there is a need to understand and share learning about complementary feeding programming, especially in challenging contexts. This is also timely given the multiple crises we are facing around the world and the compounding effects of climate-induced emergencies (including droughts and environmental degradation), widespread conflict including the war in Ukraine, and the continuing socioeconomic impacts of the COVID-19 pandemic.

In this special section, we present experiences that show how the UNICEF action framework for improving young children’s diets (UNICEF, 2020a) has been applied and used in contexts such as in Sudan, Nigeria, Myanmar and Yemen. We feature examples of the first step in the action framework, which consists of conducting a landscape analysis of drivers and determinants at both the regional and country level. We also feature country experiences of the multi systems approach to improving diets in early childhood, including through the health system in Egypt and the Social Protection system in Kenya. We also present specific emergency response actions, such as in Cox’s Bazar in Bangladesh the State of Palestine and Brazil, and innovative approaches such as the complementary feeding bowl and spoon.

We hope that this special series will help you in your efforts to design ambitious and effective programmes to protect and improve the diets of children in early childhood, especially within emergency contexts and protect our most vulnerable populations from malnutrition

So why is this issue of such importance:

Many children under the age of two are not getting the food or nutrients they need to thrive and grow well, which leads to irreversible developmental harm

At least one in every three children suffers from some form of malnutrition at the global level. Globally, only 53 countries are on track to meet childhood stunting targets, and only 57 countries are set to meet childhood wasting targets (2021 Global Nutrition Report). Regional disparities reveal inequities in progress (UNICEF, 2021). At the same time, an estimated 5.9% of the world’s children under the age of five – around 40 million – are overweight (UNICEF, WHO and World Bank, 2021), highlighting a persistent burden of malnutrition.

Change is possible: It is already happening at scale, but acceleration is needed

According to the UNICEF “Fed to Fail” report (UNICEF, 2021), over the last two decades the world has made significant progress in addressing malnutrition in children under five: for example, the prevalence of child stunting has been reduced by one-third and the number of children with stunted growth has been reduced by 55 million. These formidable achievements indicate that positive change for child nutrition is possible and is happening at scale in many countries and regions. Despite such progress, we have collectively failed to protect the right of all children to good nutrition. This has contributed to a situation where an estimated 149.2 million children have stunted growth (with around 45% of these children living in fragile or conflict-affected countries) and 340 million children under the age of five are suffering from deficiencies in vitamins and other essential micronutrients (UNICEF, 2019).

Children carry the scars of poor diets and feeding practices for life

The period between 6–23 months of age is critical in a child’s life, as the six-month mark represents the moment when a child’s energy and nutrient needs begin to exceed what is provided by breast milk alone. Exceptional changes happen, including rapid physical growth, which lead to high nutrient needs. Poor diet (inadequate quality and/or quantity of first foods; poor feeding practices) in this age group therefore contributes to poor nutritional status. The risk of stunting increases rapidly between 6–23 months and, globally, more than half of all children with wasting are under the age of two. Improving children’s diets is critical for child growth and development, as well as to address and prevent different forms of malnutrition (micronutrient deficiencies, wasting, stunting, overweight and obesity), which all contributes to achieving the Sustainable Development Goals by 2030. Critical to this is continued breastfeeding between 6–23 months, which safeguards children’s survival, growth and development and provides essential fats, proteins and other nutrients that are important to lifelong health in all settings.

Progress in improving dietary practices has been slow and there is a need to accelerate action

Currently, diets are failing in terms of timeliness, frequency and diversity

Globally, about half of all children aged 6–23 months (48%) are not fed the minimum recommended number of meals; over two-thirds (71%) are not fed the minimally diverse diets they need to grow and develop; and over one-quarter (27%) lack the benefits of the most nutrient-rich foods such as fruits, vegetables, eggs, fish or meat. In addition, around one-third (35%) of children aged 12–23 months are no longer continuing to be breastfed (UNICEF, 2021). According to the most recent Child Food Poverty Report, one in three children lives in severe food poverty (defined as eating fewer than two food groups a day) and, in the Sahel and Horn of Africa, 50% of children living in severe food poverty are fed only one – or none – of the eight recommended food groups (UNICEF, 2022). The state of children’s diets therefore remains a persistent bottleneck to greater progress on nutrition.

In many contexts – including fragile, food insecure and humanitarian contexts – families struggle to find and afford nutritious complementary foods for their children. The feeding of infants and young children may also be jeopardised by limited access to clean and potable drinking water, a lack of access to quality health services, and altered practices due to social disruptions (such as family and community breakdown, stress, time, space, lack of preparation/cooking facilities/equipment, etc.). Shortages in national food supplies, seasonal scarcities, displacement and poor road infrastructure constrain access to nutritious foods especially for the poorest and most marginalised populations. Physical access is also problematic in poor urban communities where there are fewer shops selling affordable nutritious foods. When income is limited, families tend to prioritise the frequency of feeding and fuller stomachs over the quality of foods for young children. This shift was clearly documented during the Covid-19 pandemic, where, for example, in Indonesia a survey conducted among urban households in Jakarta, reported the percentage of young children consuming the minimum recommended number of food groups fell by one third in 2020 compared to 2018 (UNICEF, 2021).

Improving diets of young children is possible and important even in fragile settings

Experiences in countries that have recorded a significant improvement in diet quality over the past decade, provide evidence that change is possible at scale with the right focus, identification of barriers and investment. In line with its Global Nutrition Strategy 2020–2030 (UNICEF, 2020b), UNICEF is committed to improving the diets of infants and young children as a contribution to preventing all forms of malnutrition.

Multiple actions are needed for improving diets of infants and young children

For far too long, efforts to improve the diets of young children have been inadequate in scale, fragmented and fail to reach most vulnerable children. These efforts have also not addressed the challenges that caregivers face in feeding children what they need to grow well in a comprehensive manner. In recognition of this, we at UNICEF have developed programming guidance for improving the diets of infants and young children during the complementary feeding period (UNICEF, 2020a) (Box 1) to support more effective action through a multi-systems approach. This guidance, together with the 2021 Child Nutrition Report (UNICEF, 2021), calls for governments to take the lead in upholding every child’s right to food and nutrition, as well as for the mobilisation of policies, resources and actors across multiple systems (specifically food, health and social protection, and water, sanitation and hygiene [WASH]).

Box 1: UNICEF programming guidance: An action framework for improving the diets of infants and young children

In February 2020, UNICEF published programming guidance on improving young children’s diets during the complementary feeding period (UNICEF, 2020a). The guidance describes recent evidence on improving complementary feeding, explores the determinants and drivers of young children’s diets, and presents action frameworks for delivering nutrition results for children through the food, health, WASH, and social protection systems. It also provides guidance on monitoring and evaluating complementary feeding programmes and outcomes. 

The guidance highlights the determinants and drivers of poor diets in young children, emphasising the role of adequate food, services and practices (Figure 1). Poor diets are determined by the adequacy of foods, which is in turn driven by the availability, access, affordability, and desirability of such foods. Equally, the availability, affordability, quality and use of health, nutrition, WASH, and social protection services influence the quality of children’s diets. The feeding, care and hygiene practices of caregivers are key determinants of the quality of young children’s diets. These practices are driven by caregivers’ knowledge and time, household dynamics and social norms. 

Figure 1: The determinants of young children’s diets  

The guidance describes the most recent evidence for improving complementary foods and feeding, highlighting implementation across different systems, including health, food, social protection and WASH, at multiple levels (policy, institutional and community/household). The interventions include:

  1. Nutrition counselling and social and behaviour change communication
  2. Counselling and education on responsive feeding and stimulation
  3. Use of vitamin and mineral supplements in settings where nutrient-poor diets prevail 
  4. Access to diverse and nutritious complementary foods at household level 
  5. Access to fortified foods as needed, aligned with global and national standards 
  6. Promoting improved accessibility and use of safe complementary food, water and a clean household environment 
  7. Access to affordable and nutritious foods through social protection programmes and counselling services 

The guidance provides a framework of action as a tool to apply the systems approach (Figure 2).

The action framework has four elements that interplay to facilitate the design and implementation of evidence-based programmes: a situation analysis to understand the status, drivers, and determinants of young children’s diets; strategic actions to be implemented through systems; the adaptation to the programming context; and the need for monitoring, evaluation and learning. 

Figure 2: The UNICEF action framework to improve the diets of young children during the complementary feeding period 

What is next for the programming guidance?

UNICEF has implemented a plan for the uptake of its programming guidance at regional and country level. Regional workshops on improving the diets of infants and young children were conducted over the last two years to sensitise regional and country offices on the guidance and will continue. Regional landscape analyses, which provide a starting point for the planning of actions at both regional and country level, were also conducted.

For this issue of FEX we will share examples of applying and adapting the action framework, and the programming guidance to improve  the diets of infants and young children particularly in fragile, food insecure and humanitarian settings

So why a multi systems approach ?– at UNICEF we believe that different systems have key roles to play to improve diets in early childhood?

The health system provides multiple contact points at the facility and community levels to inform, counsel and support caregivers on infant and young child feeding and care practices, as well as to distribute dietary supplements and home fortificants (as appropriate) where poor diets and micronutrient deficiencies are common.

The food system comprises the policies, services and actors involved in the production, processing, distribution and marketing of food. It influences whether foods are available, accessible, affordable, nutritious, safe and sustainable, and can make it easier – or more difficult – for caregivers to make nutritious food choices for their young children

The social protection system forms a crucial safety net to protect vulnerable children against poverty and social exclusion, including in emergencies. It can increase families’ physical or financial access to nutritious diets by providing social transfers (food, cash and/or vouchers) and offers a platform for the delivery of essential nutrition services and the promotion of positive nutrition practices.

The water and sanitation system aims to ensure a population’s access to, and use of, safe drinking water and sanitation. These are critical to protecting young children’s diets, as poor WASH can expose children to pathogens that cause diarrhoea and other infections and can result in environmental enteropathy, leading to impaired structure and function of the small intestine. Improved access to basic WASH services can reduce the risk of diarrhoea and other infectious diseases.

Achieving the outcome of good diets for children in the first two years of life, means that countries need to leverage all four systems, prioritising strategic actions that are evidence-based, equitable and sustainable based on a country-specific analysis of barriers and bottlenecks on the determinants and drivers. This will serve to inform the programming context and the systems’ capacity to deliver.

Food insecure and fragile contexts heighten the vulnerability of children and narrow the window of opportunity to intervene

In fragile contexts, it is important to ensure timely and appropriate response to protect, promote and fulfil children’s right to nutrition. In contexts characterised by limited availability of, or access to, nutritious food, the inclusion of child-centred food assistance may be warranted. This may include providing rations of specialised nutritious food to prevent wasting, or cash-based transfers where markets function. The appropriate use of these interventions should be closely monitored, and the use of specialised products should be discontinued as soon as the situation allows the shift to more appropriate and sustainable home food diets. Box 2 provides an elaboration on how the UNICEF programming guidance applies in emergency contexts.

Box 2: Using the programming guidance in humanitarian and fragile settings?

In 2019, the Infant Feeding in Emergencies (IFE) Core Group conducted a review on complementary feeding in emergencies, which identified gaps including in coordination, assessment, preparedness and programming capacity, among others. The review found that, despite existing guidance on infant and young child feeding in emergencies (OG-IFE), there is still a gap in clear guidance on actions related to complementary feeding in emergencies. Although the UNICEF programming guidance was not specifically designed for humanitarian contexts, a review conducted by ENN and the IFE Core Group with an “emergency lens” found that its content remains relevant to emergency settings, as it considers the requirements for emergencies in most actions and identifies what elements apply to both emergency and non-emergency contexts.

Programming context

The guidance emphasises the importance of understanding the programming context and therefore of:

  • Adapting and expanding actions to respond to the specific setting, e.g. challenges affecting access and affordability of food and health services, or security issues
  • Ensuring appropriate coordination to ensure within- and across-sector coordination is taking place, including strengthening multi-sector planning and clearly defining the roles of different actors
  • Understanding the policy environment and legal frameworks driving complementary feeding outcomes in a particularly dynamic environment

Situation analysis

Any assessment of an emergency situation should consider the challenges and drivers related to the feeding of infants and young children, even if no specific complementary feeding in emergencies assessment is planned. Building on existing data and evidence can also provide insights into the drivers and determinants of feeding practices prior to an emergency. The situation analysis should review existing barriers, bottlenecks, gaps and risks that may negatively affect programming to plan actions to strengthen response and preparedness.

Multiple intervention channels

The guidance identifies actions for different humanitarian settings, including sudden onset displacement, and slow-onset emergencies. It highlights that humanitarian emergencies can aggravate existing drivers of poor nutrition, such as reducing access to nutritious foods and services, and emphasises the importance of prioritising vulnerable families with services that mitigate these risks.

The needs of specific population groups, such as young children and caregivers with disabilities, are also emphasised, highlighting the unique challenges faced in humanitarian settings and the importance of addressing these needs through tailored interventions.

Systems strengthening

The guidance emphasises the importance of building the emergency response on existing systems – food, health, social protection and WASH – to deliver nutrition results for young children. Examples of strategic actions to undertake at the policy, institutional and community/household levels are illustrated to address the drivers of children’s diets through these systems.

The guidance recommends an approach that involves building institutional capacity and supporting the government to mitigate the effect of a humanitarian crisis and facilitate sustainable recovery. It highlights that, when systems strengthening efforts continue during emergencies, they can promote community resilience and help institutionalise actions to improve children’s diets over the long term.

Monitoring and evaluation

In humanitarian and fragile settings, the generation, documentation, sharing and application of knowledge may become challenging due to the volatile nature of the context. The guidance nevertheless emphasises the importance of maintaining a framework to ensure the monitoring of infant and young child feeding indicators. A context-specific results matrix serves as a useful tool to facilitate monitoring, evaluation and learning as part of the complementary feeding response.

What’s next?

As promoted and advocated for in the Fed to Fail report, governments must take the lead in upholding every child’s right to food and nutrition. Together with national civil society, development and humanitarian partners, and the private sector, governments must mobilise the food, health and social protection systems to deliver nutritious, safe and affordable diets, essential nutrition services and positive nutrition practices for every child.

The need to transform how we tackle poor-quality diets in early childhood is urgent. If activated in the right way and held accountable, the food, health and social protection systems – and their public and private sector actors – can ensure that children benefit from the nutritious, safe and affordable diets and the essential nutrition services and practices they need to grow and develop to their full potential, especially in fragile and emergency settings.

For more information, please contact Grainne Moloney at gmmoloney@unicef.org.

References

Global Nutrition Report (2021) 2021 Global Nutrition Report. https://globalnutritionreport.org/reports/2021-global-nutrition-report/

UNICEF (2019) The State of the World’s Children 2019. Children, Food and Nutrition: Growing Well in a Changing World. UNICEF, New York. https://www.unicef.org/reports/state-of-worlds-children-2019.

UNICEF (2020a) Improving Young Children’s Diets During the Complementary Feeding Period. UNICEF Programming Guidance. UNICEF, New York. https://www.unicef.org/documents/improving-young-childrens-diets-during-complementary-feeding-period-unicef-programming.

UNICEF (2020b) Nutrition, for Every Child: UNICEF Nutrition Strategy 2020–2030. UNICEF, New York. https://www.unicef.org/reports/nutrition-strategy-2020-2030.

UNICEF (2021) Fed to Fail? The Crisis of Children’s Diets in Early Life. Child Nutrition Report. UNICEF, New York. https://www.unicef.org/reports/fed-to-fail-child-nutrition.

United Nations Children’s Fund (UNICEF). Child Food Poverty: A Nutrition Crisis in Early Childhood. UNICEF, New York, October 2022.

UNICEF, WHO and World Bank (2021) Joint Child Malnutrition Estimates, 2021 Edition. https://www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb.

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Grainne Moloney, Linda Shaker Berbari and Harmonie Bucher (). A global perspective on improving the diets of infants and young children. Field Exchange 68 , November 2022. p34. www.ennonline.net/fex/68/aglobalperspectiveiycf

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