COMMON PITFALLS REGARDING COMPLEMENTARY FEEDING PRACTICES AMONG HEALTH CARE PROVIDERS AT SOHAG GOVERNORATE

Background: The health and well-being of the child depends on the attainment of appropriate nutritional requirements which include breast or formula feeding followed by proper complementary feeding. Objective: To assess the current awareness of pediatric health care providers at Shoag Governorate (Sohag General Hospital, Sohag Teaching Hospital, Elhelal Hospital and Gerga General Hospital) regarding complementary feeding practices. Patients and Methods: This study is a comparative cross-sectional questionnaire-based study conducted among 234 health care providers (122 physicians and 112 nurses) working in pediatric departments of the above-mentioned hospitals in Sohag. The questionnaire consisted of 17 items based on the recent evidence-based clinical practice guidelines for complementary feeding practices in Egypt, June 2018. Data was collected over 12 months and coded manually and analyzed by using statistical package for social science version 25. Results: The studied healthcare providers (both physicians & nurses) experience inadequate knowledge in several aspects of complementary feeding. For physicians, the main pitfalls regarding complementary feeding that deviated from the recommended guidelines were for: time of water introduction in breastfed infants (96.7%), honey introduction (92.6%), introduction of fruit juice (86%), advisable first food (64.8%), introduction of dairy products (59%), iron supplementation (59%) & water in non-breastfed infants (36.1%) respectively. Conclusion: The present study demonstrated that knowledge of the studied pediatric health care providers is not optimum in several aspects of complementary feeding and


INTRODUCTION
The first 2 years of the child's life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduce the risk of chronic disease, and foster better development overall (WHO, 2021).
Complementary feeding (CF) as defined by the World Health Organization (WHO) is "the process starting when breast milk alone is no longer sufficient to meet the nutritional requirement of infant so that other food and liquid are needed along with breast milk (WHO, 2021).
To promote optimal child growth and development, the WHO recommends exclusive breastfeeding (EBF) for the first 6 months of life followed by continued breastfeeding and gradual introduction of appropriate and safe complementary foods until age 23 months (WHO, 2021).
In Egypt most health surveys showed that considerable percentage of children aged 6-23 months were suffering from stunting, Protein energy malnutrition (PEM) and micronutrients deficiencies especially iron, vitamin A and D In contrast to the large literatures on breast and formula feeding less attention has been paid to complementary feeding period. The more limited scientific evidence base is reflected in considerable variation in complementary feeding recommendation and practices between and within countries (Fewtrell et al., 2017).

AIM OF THE STUDY
To assess the current awareness of pediatric health care providers at some Sohag hospitals (Sohag General Hospital, Sohag Teaching Hospital, Elhelal Hospital and Gerga General Hospital) regarding complementary feeding practices.

SUBJECTS AND METHODS
This is a comparative crosssectional study that was carried out to detect the common pitfalls regarding CF practices among health care providers in pediatric departments of some Sohag hospitals in order to put a plan for application of the optimal complementary feeding practices as recommended by the recent evidence based Egyptian guidelines, June 2018.

Ethical consideration:
• Approval by the ethical committee of Al-Azhar Faculty of Medicine was obtained before the study.
• An informed written consent was obtained from all participants before getting them involved in the study.
• The steps of the study, the aim and the potential benefits all were discussed with the participants.
• Confidentially of all data were ensured.
• The physicians and nurses had the right to withdraw from the study at any time without giving any reasons.
• No conflict of interest regarding the study or puplication.
Disclosure of finance: no financial support for the study and puplication.

Sample size:
The studied sample included two hundred thirty-four healthcare workers, 122 physicians with a mean age 35.8± 9.3 years and 112 nurses with a mean age 26.5±6.9 years. They were randomly selected from Sohag General Hospital (SGH), Sohag teaching hospital (STH), Elhelal hospital and Gerga general hospital (GGH) at Sohag governorate.
Inclusion Criteria of health care providers: Egyptian pediatrician and nurses working in pediatric departments of the previously mentioned hospitals and willing to participate.

Exclusion
Criteria: other Specialists and general practitioners.

Study setting:
The study was conducted at all pediatric wards inpatient and outpatient of Sohag General Hospital (SGH), Gerga general hospital (GGH) both belong to Ministry of Health, Sohag teaching hospital (STH) that belongs to the general organization for teaching hospitals and institutes, and ElHelal hospital which belongs to the health insurance hospitals.
Subjects: all health care providers (physicians and nurses) that care for neonates, infants, children, were recruited from pediatric units of the previously mentioned hospitals. The total number of possible participants in the designated hospitals during the time of the study was 168 physicians, 130 nurses. They were chosen every other day using simple randomization and after receiving approval from the ethical committee of Al-Azhar University, a total sample of 234 of health care providers (78.5% of the total number) were completed from the previously mentioned hospitals during the period from September 2019 to September 2020.

Methods:
The questionnaire: after explaining of the purpose of the study, an informed consent was obtained from the studied health care providers before fulfillment of the face-to-face structured interview questionnaire. The designed questionnaire was prepared to meet the objectives of the study to identify common pitfalls regarding complementary feeding practices among studied health care providers and the questionnaire started by taking personal data: age, sex, affiliation, mobile number, place of work, duration of experience and workshops regarding complementary feeding.
Then the questionnaire included 11 questions about various items of complementary feeding that were verified as follows: • Duration of exclusive breast feeding: the correct duration according to WHO (2010) is six months.
• Time of introduction of Solid Foods: -According to WHO recommendations, WHO (2010) the best time is sixth months.
• First food is advised to be introduced suggested to be iron fortified cereals in Egyptian guidelines (2018).
• Recommended daily frequency of meals for age groups: -Meals of Complementary Foods Should be provided 2-3 times per day at 6-12 months of age and 3-4 times per day at 12 -24 months of age WHO (2003).
• Time of introduction of whole cow's milk: is after one-yearold age; WHO (2003).
• Time of introduction of yogurt and dairy product: -the correct answer is at age of sixth months WHO (2003).
• The best time to introduce honey: is at age of nine months' Egyptian guidelines (2018).
• Time of introduction of Fruit Juice to infant: the correct answer is not before one-year Egyptian guidelines (2018).
• Time of water to be introduced to breastfed infant and nonbreastfed infant: Breastfed infants: with solid foods & nonbreast fed infants at 0 day, Egyptian guidelines (2018).
• Time of introduction of iron supplementation to infants:the correct answer is six months, Egyptian guidelines (2018).
• Time of introduction of Vitamin D: The correct answer is 0day, Egyptian guidelines (2018).
An Arabic version was done through the following steps for nurses to answer the questionnaire.
Statistical Analysis: a. Descriptive statistics: quantitative data: mean and standard deviation were used to measure central tendency and dispersion and qualitative data: frequency of occurrence was calculated by number and percentage.
b. Analytical statistics: comparing between groups was done using: students T test for Quantitative data of two independent samples. ANOVA test for more than two groups of normally distributed data, mann-Whitney U test between two groups of non-normally distributed data and pearson Chi square test used for qualitative data.
1. The value of significance was taken at (p-value ≤0.05).

The results presented in tables and figures.
Finally, writing the thesis, discussion, English and Arabic summaries, conclusion and recommendations.

RESULTS
The results of the current study are arranged into the following sections: • Section (1): Characteristics of physicians in the studied hospitals. • Section (2): Characteristics of nurses in the studied hospitals. • Section (3): Comparison between physicians and nurses in the studied hospitals.  The previous table shows that there was statistically significant difference at all items about complementary feeding (between physicians) except for time of fruit juice introduction.    The previous table shows that there was statistically significant difference at all the above points. 0.3 * p ≤ 0.05, statistically significant. aOther for physicians 7 mentioned at 8 months and 2 at 9 months while nurses 5 mentioned at 8 months and 2 at 9 months bother for physicians they mentioned at 8 months while nurses mentioned at 18 months. cHoney: for physicians 9 mentioned at 9 months,2 at 8 months, 2 at 6 months and 2 since birth or first month. While nurses 16 mentioned at 9 months, 3 at 8 months, 22 at 6 months, 1 at 5m, 3 at 4 m and 2 since birth.
This table shows that there was statistically significant difference between physicians and nurses about items of complementary feeding except for time of cow's milk, honey and fruit juice introduction.  (Chouraqui et al., 2019).
For optimal growth of infants, the world health organization/ UNICEF recommend exclusive breast feeding for the first six months and the introduction of complementary feeding at age of six months (WHO, 2018;UNICEF et al., 2011).
As regard the type of first complementary food to be introduced, we found lack of awareness in all studied hospitals between Physicians about the best food to be introduced as recommended in Egyptian guidelines which is iron fortified cereals, the highest percentage was at SGH (52.5%) followed by STH (33.3%) then at Elhelal hospital (25%) and finally at GGH (0%).
On reviewing the answer of this same question among studied nurses, we found that the highest percentage of correct answer among them was at Elhelal hospital (50%), followed by GGH (33.3%) then SGH (10%) and the least percentage was at STH (5.9%).

Australian
infant feeding guidelines (2013), reported that in order to prevent iron deficiency, iron containing nutritious foods are the first recommended foods to be introduced.
Given the high prevalence of iron deficiency anemia among Egyptian children, estimated to be 29.9% in preschool children by WHO in (2014); Egyptian guidelines (2018) recommended that the first food to be introduced is iron fortified cereals and iron nutritious foods.
In the present study, regarding the question of whole cow's milk introduction, 100% of physicians at Elhelal hospital advised cow's milk after 1year, followed by 98.3% at SGH then 76.2% at STH and the least percentage was 68.2% at GGH. This means that more than half of Physicians in all hospitals included in our study correctly advised cow's milk after 1 year of age. In the present study, review of CF practices regarding the question of advising yogurt and dairy products at sixth months revealed that physicians at GGH recorded the highest percentage of correct answer (100%), (that agreed with WHO and Egyptian guidelines) followed by Physicians at Elhelal hospital (35%) then Physicians at SGH (33.9%) and the least percentage was at STH (4.8%).
While the percentage of nurses who advised yoghurt and dairy products at sixth months was highest at GGH (83.3%) followed by SGH (75%) then STH (53.9%) and the least percentage was at Elhelal hospital 34.4%.
With the exception of liquid cow milk, which is not recommended before 12 months of age, WHO and Egyptian guidelines recommended giving whole cream dairy products as yougurt, cheese and pudding starting after 6 months (WHO, 2010; Egyptian guideline, 2018).
Regarding honey introduction at the age of nine months, we noticed that only 15.3% of Physicians at SGH who answered correctly and no one in the remaining hospitals advised that.
Based on available evidence in Egyptian population the committee suggests honey introduction in small amounts starting from 9 months (Egyptian guideline, 2018).
As regards introduction of fruit juice after one year in our study, only (20%) of physicians answered correctly (not before 1year) at El helal hospital followed by 19% at SGH then 9% at GGH and no one answered correctly at STH.
While the percentage of nurses who answered correctly regarding to this question was (37.5%) at SGH, followed by (33.3%) at GGH, then (6.2%) at Elhelal hospital and the least percentage was at STH (5.9%).
Energy providing liquids (fruit juices, vegetable fruits, soda pops and organic products drinks) are not beneficial for babies in their early life as it provides only minimal amount of nutrients and they replace other food sources that can give nutrition (AAP, 2016;Zigler, 2011).
In the present study, regarding the question of iron supplementation at sixth months of age, we found that physicians at STH had the highest percentage of correct answer (61.9%) followed by Physicians at SGH (45.8%) then GGH (31.8%) and the least was at Elhelal hospital (15%).
On the other hand, the percentage of nurses included in our study who advised introduction of iron at sixth months was highest at GGH (50%) followed by Elhelal hospital (43.8%) then SGH (30%) and the least percentage was at STH (11.8%). Soliman et al. (2020) in Assiut city conducted on infants (12-24 months) showed a high prevalence of IDA, 41.6% of the study population.

Again in Egyptian study by
According to WHO (2016), daily iron supplementation is recommended as a public health intervention in infants and young children aged 6-23 months, living in settings where anaemia is highly prevalent, for preventing iron deficiency and anaemia in a dose of 10-12.5 mg elemental iron for 3 consecutive months of year (WHO, 2015). Being a highly prevalent areas for iron deficiency anemia Egyptian guidelines adopted these recommendations in (WHO, 2018).
In our study, we found that nearly all Physicians in all hospitals recommended introduction of vit D from 0 day, this question had the highest correct answer among physicians.
Regarding to nurses in our study who answered correctly about vit D supplementation from birth, we found that the highest percentage was at Elhelal helal hospital (84.4%,) followed by SGH (82.5%) then GGH (66.7%) and the least percentage was at STH (47.1%).
In (2018), Egyptian guidelines has adopted AAP (2016) recommendations that all infants should be supplemented with vit D (400 IU) since birth, as our country is located in geographic distribution of vitamin D deficiency region (Hussein-Nezhad and Holick, 2013).
Regarding to daily frequency of meals at age of 6-12 months we found that 100% of Physicians at GGH and STH advised 2-3 meals, while 95% and 93.2% advised that at Elhelal hospital and SGH respectively. At age of 12_24 months we noticed the same order of correct answer without statistically significant difference between hospitals.
In nurses also, we found that most of them answered correctly regarding this question at age of 6-12 months, the highest percentage was at GGH (100%) followed by STH (94.1%), then at Elhelal hospital (93.8%) and at SGH was (72.5%). But for the frequency of meals at 12-24 months, the highest percentage of correct answer was at Elhelal hospital (96.9%) followed by STH (94.1%), then GGH (83.3)% and the least percentage was at SGH (72.5%).
For the average healthy infant, WHO recommended that meals of complementary foods should be provided 2-3 times per day at 6-8 months of age and 3-4 times per day at 9-11 and 12 -24 months of age, with additional nutritious snack (such as a piece of fruit or bread) offered 1-2 times per day, as desired (WHO, 2010;Egyptian guideline, 2018).
Regarding the question of introduction of water with solid foods in breastfed infants among Physicians, we found that only 5% in SGH and Elhelal hospital answered correctly and no one answered correctly in GGH and STH, this is the question of least percentage of correct answer.
On the other hand, for nonbreastfed infants the correct time of introduction of water is since birth according to WHO (2005); Egyptian guidelines (2018). We found all Physicians answered correctly at GGH (100%) followed by Physicians at STH (66.7%) then in Elhelal hospital (55%) and the least percentage was at SGH (52.5%).
Up to the age of 6 months, breastfed infants generally don't need any supplementary fluids, while formula fed infants may be offered cooled boiled water, this does not apply to breastfed infants, as offering other fluids may interfere with the demand supply basis of milk production (Food Safety Authority of Ireland, 2011).
Australian infant feeding guidelines (2013) also recommended that exclusively breastfed infants don't require additional fluids up to 6 months of age.
In comparison between physicians and nurses in our study, we found that Physicians represent 52.1% of the studied sample and nurses represent the remaining 47.9%.
Regarding the question of duration of exclusive breast feeding, the percentage of Physicians who answered correctly for six months was (76.2%) which was less than nurses (97.3%). Also, the percentage of nurses who answered correctly regarding the question of solid food introduction at sixth months was 88.4% that was higher than Physicians (75.4%).
The percentage of Physicians who advised iron fortified cereals to be the first food introduced was higher than nurses (35.2% versus 21.4%) respectively. Also, the percentage of Physicians who advised whole cow's milk after 1year of age was higher than nurses (89.3% versus 81.2%) respectively.
Regarding yogurt and dairy products introduction at 6 months, the percentage of nurses who answered correctly was more than Physicians (57.1% versus 41% respectively).
The percentage of nurses who advised introduction of honey at nine months was more than physicians (14.3% versus 7.4%) respectively.
On review of the question of fruit juice introduction after 1year of age which is the correct answer according to ESPGHAN (2017); Egyptian guidelines (2018), the percentage of nurses was higher than Physicians (18.8% versus 14%) respectively.
All the previous results showed statistically significant difference between Physicians and nurses except for the question of fruit juice introduction.
Regarding the question of iron and vitamin D supplementation, we found that 41% of Physicians answered correctly regarding iron supplementation at 6 months compared to 29.5% of nurses. The percentage of Physicians who advised vit D introduction at 0 day was 99.2%, while in nurses it was 71.4%, both with statistically significant difference.
The percentage of Physicians who advised the appropriate daily number of meals at 6-12 months was (95.5%) compared to (86.6%) of nurses. Also, the percentage of Physicians who advised the correct daily number of meals at respectively) with statistically significant difference.
In agreement with our study, Nsaih-Asamouh (2018) in Ghana studied knowledge of health worker in CF and found that: The majority (82.3%) of the health care workers knew the recommended daily feeding frequency for breastfeeding children aged between 6 and 8 months, (81.3%) also knew the recommended feeding frequency (9-24months) age group However, only 6.8% of the health care workers knew that nonbreastfeeding children aged between 6 and 23 months should be fed 4 or more times daily. Again, only 9.9% of the health care workers knew that nonbreastfed children age 6-23 months should receive milk or milk products two or more times a day to ensure that their calcium needs are met.
Regarding the question of introduction of water with solid foods for breastfed infants, only 3.3% of Physicians advised that compared to 21.4% of nurses who advised that, while in nonbreastfed infants, the percentage of Physicians who answered correctly at 0 day was more than nurses (63.9% versus 46.4% respectively), with statistically significant difference.
Early introduction of water for breastfed infants is common malpractices in complementary feeding, (Gupta et al., 2007) who studied effect of early introduction of water and CF in northern Senegal and found that; water was introduced to about 85% of children in the first 3 month of life.
In the present study, we noticed poor knowledge of Physicians and nurses regarding several aspects of CF practices that need to be updated and enhanced by continued nutritional education programs.
Limitation of the Study: some participants showed negative attitude & didn't show much cooperation to complete all items of the questionnaire, and they were excluded and data was collected during working days, doctors and nurses were busy and had to be contact many times to finish the target.

CONCLUSIONS
The present study demonstrated that knowledge of the studied pediatric health care providers is not optimum in several aspects of complementary feeding and need to be updated and enhanced by regular training courses and follow up in that field.

RECOMMENDATION
The present study demonstrated that knowledge of the studied pediatric health care providers is not optimum in several aspects of complementary feeding and need to be updated and enhanced by regular training courses and follow up in that field.