Mothers’ knowledge about infant and young child feeding practices and their health impacts.

Background: Breastfeeding has always been proven beneficial for infant and mother’s health in every era. Thus, the present study was conducted to assess mothers' infant and young child feeding practices in Karachi, Pakistan, and their knowledge about the health impacts on their children. 
Methodology: A cross-sectional survey-based study including 1200 mother-child pairs was conducted from March to November 2020. Mothers' knowledge toward indicators for assessing infant and young child feeding practices (IYCF) questionnaire was used and scored using a four-point Likert scale. 
Results: Out of the total, most of the females were un-educated (97%), and the majority of them belonged to the middle class (49%). It was also found that 96% of the mother had breastfed their child, and more interestingly, 35% breastfed their child for 2 years. Almost 82% of mothers preferred breastfeeding and considered it necessary for the child. It was found that females had excellent knowledge about the young child feeding practices and their health impacts (66%). Furthermore, mother age, marital status, socioeconomic status (SES), number of children, occupation, personal and family disease history were significantly associated with the knowledge level of the mothers (p<0.05). 
Conclusion: It was found that females had excellent knowledge about the young child feeding practices and their health impacts. Future research is recommended to compare mothers' knowledge regarding infant and young child feeding practices in different geographical areas and districts of Karachi.


Introduction
Early development in infants occurs during the first six months after their birth, and the initial source of nourishment is breast milk. But the food industry plays crafty marketing tricks to sell infant formula. Infant milk formula substitutes breast milk for infants with special needs, i.e., lactose intolerance or other medical conditions. However, it cannot replace breast milk as it is essential for infant nourishment and immunity. Breastfeeding has always been proven beneficial for infant and mother's health in every era. Despite all the health benefits and complete diet nutrients, the food industry promotes lab-made infant milk formula equivalent to breast milk. There is scientific evidence that breastfeeding has a long-term impact on a child's health. UNICEF (United Nations International Children's Emergency Fund) and WHO (World Health Organization) recommends and promotes breastfeeding practices for improving infant's health 1 .
Human milk or breast milk is naturally composed to provide all the essential nutrients required to develop and protect against diseases, including respiratory tract infection and gastrointestinal tract illness, and diabetes. Breastfeeding reduces the chances of exposure to environmental contaminants that might be introduced through feeding utensils; human milk contains bioactive compounds that aid the development and regulation of the immune system 2 . Furthermore, exclusive breastfeeding could also prevent respiratory diseases. According to a study, 6% of infants under one year are reported to be hospitalized for LRTDs (lower respiratory tract diseases) and, most commonly, asthma in the USA, which is now increasing annually by ten-folds. According to recommendations from the American Academy of Pediatrics, mothers must exclusively breastfeed their infants up to 6 months; but 31% of mothers only continued breastfeeding until the age of 6 months of infants 3 .
The pursuit of breastfeeding is beneficial for infants and provides health benefits and protection to the feeding mothers. Exclusive breastfeeding lowers the risk of breast cancer in mothers compared to mothers who never breastfed their infant. Similarly, it was found that women who had breastfed their infants for a short period were at less risk, while women who had never breastfed their child had an increased risk of developing ovarian cancer with 27%. Further, a longer duration of breastfeeding is associated with better maternal health. Another critical factor is psychosocial effects; breastfeeding allows the mother to bond and gets closer with their infants. Breastfeeding might also lower the risk of postpartum depression; it is a severe condition that could affect a mother's and child's health. Most women in our society (13%) experience postpartum depression after childbirth 4 .
Several studies have been conducted previously to determine the prevalence of young and infant child feeding practices among mothers but the comparison data is still inadequate [5][6][7] . A study was conducted in 2001 in Bahawalpur and found that the breastfeeding rate among mothers was only 30% 8 . Further, another study found an even lower rate of breastfeeding among mothers that is 16% at six months of age in Multan 9 . Even more, bottle feeding practices were increased (79%) as per the study conducted in Hyderabad 10 . Similarly, in India, almost 93% of females bottle-feed their infants, as per the record of WHO 11 . Pakistan is a developing country facing rapid urbanization with lower economic status and literacy rate. Therefore, research should be conducted to assess infant and young child feeding practices of mothers in Karachi and also the impact of bottle feeding on mother and child health. Thus, the present study was conducted to assess infant and young child feeding practices of mothers in Karachi, Pakistan, and their knowledge about the health impacts on their children.

Methodology
This was a cross-sectional survey-based study including 1200 mother-child pairs of different districts of Karachi city, including Korangi district, Central district, East district, and Malir district, recruited through purposive sampling technique from March to November 2020.
All those females who delivered a child were included, while caregivers/nannies and single females or who never delivered a child were excluded from the study sample. The study protocol was reviewed and approved by the Dadabhoy Institute of Higher Education (Reference no: DIHE/R&D/ERC/2019-04). The infant and young child feeding practices (IYCF) questionnaire was used for the assessment of knowledge of mothers toward indicators 12 . The mothers' knowledge was rated to assess their infant and young child feeding (breastfeeding, infant formula feeding). The scoring was done using a four-point Likert scale, i.e., 1 for strongly agree, and 4 denoting strongly disagree levels, respectively. The cutoff point was 50 for the mother's knowledge. SPSS version 20.0 was used for statistical analysis. Categorical variables were assessed using frequencies and percentages, whereas the Chisquare test analyzed the associations and correlations. Statistical significance was set at p < 0.05.

Results
The total population included in this study was 1200 females aged between 19-60 years of age. Most of the females were uneducated (97%). The majority of the population belongs to the middle class (49%). Most of the studied females had one child (48%). It was found that most of them were housewives (57%) and had a family history of diabetes (49%), whereas most of them were hypertensive (18%) ( Table 1). It was found that 75% of children aged under three years and 85% of mothers were the child's primary caregiver child. It was also found that 96% of the mother had breastfed their child, followed by two years (35%). Almost 82% of mothers preferred breastfeeding. Results also found that 47% of mothers preferred infant formula milk over breastfeeding due to a low breast milk supply ( Table 2).  (5) It was found that females had excellent knowledge about the young child feeding practices and their health impacts (66%). Whereas 33% of females had average knowledge, and only 1% females had poor knowledge about the infant and young child feeding practices and their health impacts.
When the knowledge level of the mothers was assessed in association with the demographic variable, significant association was found with age of mother (p-value= 0.032), marital status (p-value= 0.015), socioeconomic status (SES) (p-value= 0.04), no of children (p-value= 0.001), current occupation (p-value= 0.002) and disease of a mother (p-value= 0.019) ( Table 3). When the association of infant formula milk was assessed with the increased risk of infant diseases, a significant association was found with a higher risk of acute media otitis (P-value= 0.00), asthma (P-value= 0.00), diabetes (P-value= 0.00), eczema (P-value= 0.00), and obesity (P-value= 0.01) among the children who were consuming infant formula milk (Table 4).

Discussion
The current results revealed that the infant and young child feeding practices were excellent as per the data obtained by the questionnaire. This is in agreement with the previous studies conducted in Pakistan 13 15,16 . It is evident from the data that mothers' education is associated significantly with the initiation of complementary foods on time and feeding practices 14 . This might reflect the education system, which provided adequate quality education about nutrition to the mothers 17 .
Most of the women who participated in the current study belonged to middle-class families; they preferred breastfeeding over infant formula milk due to cultural importance, understanding of longterm health benefits of breastfeeding, and sometimes unaffordability of formula milk.
Breastfeeding is not only economically friendly but tends to affect the environment positively. Unlike breast milk, infant formula requires adequate packaging to keep it safe from different environmental factors that may adversely alter the composition. Most of the packaging requires disposal either by burning or landfill, while some of the packagings can be recycled 18 . Other than that, breastfeeding helps control the birth rate, and it is suggested to prolong and maintain breastfeeding practices to reduce the birth rate in Pakistan 12 .
Socioeconomic status, mother's education, support from family members, and professional support from doctors and health care personnel acted as a positive force to maintain breastfeeding. On the other hand, pressure from in-laws as bottlefed infants are chubby and look healthier. Promotional advertisements of milk formulas can negatively impact and result in the discontinuation of breastfeeding and switching to infant formulas 19 . Sometimes quitting breastfeeding is not the mothers' choice but lack of awareness, cultural belief, wellness of mother, and other misconceptions. Some previous studies also showed that regardless of all benefits of breastfeeding and adverse effects of infant milk formulas, mothers still prefer infant formulas 20 . Not to forget, there is a massive decline in breastfeeding in urban areas, while in rural areas, the women breastfeed their infants for a longer time but initiate breastfeeding after a few days of childbirth 21 . Another reason why mothers preferred formula milk/bottle feeding was time management. Working women cannot manage feeding practice with working hours 22 .
According to a WHO report, only 37% of mothers in Pakistan exclusively breastfed infants up to 6 months. This could cause diarrhea, a leading cause of death among infants worldwide 23 . Infants fed on formula milk are also associated with weight gain rapidly; however, it is evident that infant formula milk is associated with an increased risk of obesity due to the high content of protein in formula milks 24,25 . Pakistan alone has reported an estimated 15% to 20% childhood obesity, and Karachi, the metropolitan city, had a proportion of 6% to 19% children suffering from obesity 22,26 . Breastfed babies have benefits, and they are less prone to obesity, while babies fed on Infant formula milk are at higher risk of obesity in childhood 27 .
Similarly, formula feeding had been associated with more childhood infections, most importantly otitis media. Agency for Healthcare Research and Quality (AHRQ) reported that formula-fed children are at increased risk of chronic diseases such as obesity, asthma, and diabetes type 2, which are major chronic diseases in children in the United States of America and increasing over time 4 .
Breastfeeding has also been found to be associated with decreased risk of sudden infant death syndrome (SIDS) in developed countries. Infants feeding on formula milk are at a higher risk of SIDS; other studies conflict with the idea of the link between SIDS and infant formula4; however, a meta-analysis study showed that exclusively breastfed infants develop resistance and protection against SIDS 28,29 . Some studies report indirect or direct links of breastfeeding with reduced risk of asthma and other respiratory tract infection 30 . More than 378,000 babies die within the first year of their life, and this is evident through a study that proves that 22% of deaths could be prevented if mothers initiate exclusive breastfeeding practices, and 13% of deaths can be prevented if breastfeeding practices are increased up to 90% in Pakistan 22 . Another obstacle in breastfeeding is the burden on mothers belonging to middle-class families. They have to manage all house chores, and they don't have enough time for infant care; it is the responsibility of other family members to play their part 31 .
There were a few limitations for this study; most women did not cooperate with the surveys as they were not comfortable talking on a topic outside their comfort zone. The primary difficulty in this study occurred due to the pandemic situation, the data was only collected from specific areas of Karachi, and most data collection was done online. The survey area was not vast due to the restrictions placed by the government on travel considering the virus outbreak; thus, this study still has room for improvement and can be furthered post-pandemic to be more thorough and better versed.

Conclusion
It was found that females in different districts of Karachi had excellent knowledge about the young child feeding practices and their health impacts. Further, breastfeeding decreases the likelihood of childhood diseases related to breastfeeding. Plausible explanations for the observed association might be related to the theory that breastfeeding has always been proven beneficial for infant and mother's health in every era. Human milk or breast milk is naturally composed to provide all the essential nutrients required for the development and protection against diseases, including respiratory tract infection and gastrointestinal tract illness, and diabetes. However, future research is recommended to compare mothers' knowledge regarding infant and young child feeding practices in different geographical areas and districts of Karachi.