Abstract

Background

The WHO sets evidence-based guidelines for infant feeding. Adhering to the WHO guidelines ensures that infants receive the proper nutrition and thus is associated with healthy growth and development.

Aim

To describe breastfeeding and complementary feeding practices (CFPs) for infants and young children and identify determinants of appropriate feeding practices.

Methods

This cross-sectional study was performed via structured interviews with mothers living in Saudi Arabia’s Eastern Province who had children aged 6–24 months. To evaluate their adherence to the recommended WHO practices, a scoring method was applied (0–9).

Results

395 mothers were interviewed. The rate of breastfeeding within the first hour, and exclusively breastfeeding for six months was both 25%. Multivariate analysis showed that exclusive breastfeeding for at least six months was less likely in middle-income mothers were less likely to exclusively breastfeed for six months than high-income mothers (OR = 0.32; 95% CI: 0.18–0.57; p &±ô³Ù; 0.001). Mothers without domestic help were also less likely to exclusively breastfeed (OR = 3.0; p < 0.001), as were those not living with their husbands (OR = 2.1; p = 0.007). Multiparous mothers and those with higher education were more likely to breastfeed than high school graduates (OR = 2.3, p = 0.02; OR = 4.4, p = 0.015, respectively). Timely breastfeeding initiation within the first hour was more common in term infants than preterm infants (OR = 5.3; p = 0.033), and infants born through normal delivery were four times more likely to initiate breastfeeding early (OR = 4.0; p &±ô³Ù; 0.001).

For CFPs, 42% of participants introduced solid food at six months. 55% of mothers reported poor CFPs, primarily due to inappropriate timing of solid food introduction, choking hazards, and delayed introduction of family meals. Good CFPs were positively associated with higher maternal education, increased income, and living with a husband.

Conclusion

Partial compliance with WHO CFP standards need improvement. Interventions should raise awareness of factors leading to poor compliance and support early breastfeeding initiation and continuation. Low-income and less educated families appear to be most in need of support.

Background

Optimum breastfeeding and complementary feeding practices (CFPs) are key for children’s health and survival. The World Health Organization (WHO) recommends initiation of breastfeeding, within the first hour of life, exclusive breastfeeding (EBF) for six months, and introducing of age-appropriate complementary foods at six months while continuing breastfeeding for up to two years. However, globally, less than half of infants were exclusively breastfed from 2015 to 2020, and less than 25% of children aged 6–24 months are fed according to the recommended CFPs, including dietary variety, adequacy, and feeding frequency [1].

In Saudi Arabia, the need for optimum breastfeeding is well-established, based on the Holy Quran, and to recommendations of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) [2]. Despite the well-recognised importance of optimum breastfeeding, inappropriate practices are prevalent in the Middle East [3]. A recent meta-analysis assessing the rates of breastfeeding initiation and exclusivity and the factors that may affect such practices in the Middle East found that only 34.4% of infants were breastfed in the first hour of life, with the lowest level being 11.4% in Al-Hassa Province in Saudi Arabia. It also found that only 20.5% of infants in the Middle East were exclusively breastfed for the first six months of life. The delivery mode and maternal employment are the factors most frequently reported as influencing the timely initiation and continuation of breastfeeding [4].

While the early introduction of solid food can increase the risk of developing non-communicable diseases later in life, particularly obesity and cardiovascular diseases, a late introduction can also increase the risk of undernutrition [5, 6]. A study assessing CFPs in the Middle East found that suboptimal feeding practices were common. Countries with timely introduction of complementary food included Oman and Bahrain (89% and 66%, respectively). In contrast, Saudi Arabia, Iraq, the United Arab Emirates, and Lebanon had higher proportions of infants receiving solid food early, between four and six months of age (81%, 79%, 70%, and 53%, respectively) [7].

In Tabuk city, Saudi Arabia, a cross-sectional study conducted in 2016 concluded that a 62.5% of infants were given solid food before five months of age, compromising the frequency and duration of breastfeeding. Significant factors contributed to this early introduction included younger mothers, shorter education duration, maternal employment, low income, Saudi nationality, caesarean section, and inadequate breastfeeding for the first six months [8]. Similarly, an early study assessing infant feeding trends and adherence to WHO recommendations among mothers of children under three years in Saudi Arabia found that 91.6% of infants received breast milk while 8.4% received only formula. However, the breastfeeding declined with age, falling to 10.2% and 1.8% by six and twelve months, respectively. Moreover, only 23.2% of new-born were breastfed within the first hour of life, and complementary foods were introduced to 81.5% of infants at between four and six months of age [9].

During the first four to six months, the body’s iron stores begin to deplete. Without adequate nutrient intakes from solid food starting around six months, iron-deficiency anaemia can develop. Additionally, delaying the introduction of solid food for longer than six months can lead to delays in the development of important feeding and motor skills, such as chewing, and adapting to different food textures.

While breastmilk remains a vital source of nutrition after six months, delaying solid introduction can lead to stunting and wasting. Moderate wasting and stunting were found in a community-based study on the prevalence of malnutrition in 15,516 Saudi children below the age of five from 13 regions (9.8 and 10.9%, respectively) [10]. These results indicate the need to reduce the malnutrition rate and improve the nutritional status of children in Saudi Arabia. To achieve this, it is important to identify the determinants of feeding practices in Saudi children. To our knowledge, no previous study has focused CFPs in the Eastern Province of Saudi Arabia. Therefore, we sought to fill this research gap and support the planning of targeted interventions to enhance feeding practices.

This study aimed to assess the feeding practices for infants and young children aged 6–24 months, compare them with WHO recommendations, and identify the factors associated with feeding practices in the Eastern Province of Saudi Arabia.

Methods

This cross-sectional study was conducted in four cities -Khobar, Dammam, Dhahran, and Qatif in the Eastern Province of Saudi Arabia, the third-largest province, which is home to 16% of the total population [11]. In the Eastern Province, 26.7% of the population comprises children aged 0–14 years [11]. Data were collected from mothers of children aged 6–24. Data were collected between September 2021 and April 2023. Children with mental, medical, and congenital conditions that interfered with normal feeding, and those who lived outside the Eastern Province, were excluded. Convenience sampling was used to select the participants.

This study was approved by the research ethics committees of Imam Abdulrahman bin Faisal University (ref: IRB-UGS-2022-03-043), Maternity and children hospital in Dammam(ref: EXT-MNT-2022-001) and Qatif Central Hospital in Qatif (ref: QCH-SREC0 33 /2022).Official approval was obtained from Dr Sulaiman Alhabib hospital in Alkhobar. Consent was obtained from the mothers before the interviews were held.

Data collection

Before conducting this study, the structured interview guide was validated through experts opinions and a pilot study of 40 participants. The reliability was considered acceptable (α = 0.6). The interview questions were developed using WHO recommendations and were grouped into four components [1] maternal and child’s characteristics; [2] maternal past and present breastfeeding practices; [3] complementary feeding practices, and [4] additional questions (Supplementary 1).

Sample size

The sample size was calculated based on the pilot study findings. With the expected proportion of mothers with good CFPs as 50%, and assuming 5% absolute precision, the minimum required number of participants for this research was 384, where type 1 error was fixed as 5%.

The Sample size was calculated using nMaster 2.0 software [12] and the method used was single proportion estimation-absolute precision. Accordingly, we sought to recruit 400 mother–child pairs.

Ultimately, 402 mothers were interviewed using our structured interview guide. Most participants (n = 326) were interviewed in-person interview, while (n = 76) were interviewed via phone call when in-person interview was not feasible. Participants were approached from five hospitals and the community.

Evaluation of feeding practices

To assess CFPs, elements of the WHO recommendations for children aged 6–24 months – described in Box 1) [1, 13] – were included in the interview questions, and the mothers’ practices were evaluated against those recommendations using a scoring method developed for this study to provide a quantitative measure of the adherence to the WHO CFP recommendations. This was applied to nine components of the WHO CFP recommendations, which were given a score of one if the mother adhered to that component. Consequently, the total score ranged from zero to nine. The breastfeeding practices related to the initiation and duration of feeding. The WHO also recommends not giving food to infants that could lead to choking. To address this, a list of food items with a choking hazard was obtained from the Centres for Disease Control and Prevention. This list was used to explain the common foods that may cause a choking hazard to mothers interviewed [14].

Data management and statistical analysis

The data collected were reviewed and cleaned before analysis. Outlier values were identified and modified on a case-by-case basis. Data were analysed using IBM SPSS Statistics, version 28 and RStudio [15, 16]. Frequency tables were compiled for the maternal and infant characteristics. Associations between different variables were tested, including maternal and child characteristics with CFP components, using the chi-square test. The results of univariate and multivariate logistic regression analysis were presented as Odds Ratio (OR) and 95% Confidence interval (CI). A bar plot and word cloud plot were created for graphical representation. A p-value ≤ 0.05 was considered statistically significant.

Box 1 WHO recommendations for breastfeeding and CFP in children aged 6–24 months, used to evaluate feeding practices in the study sample [1, 13]

Results

Description of study participants

We interviewed 402 mothers, of whom 395 were included in the final analysis. Overall, 83% of the mothers were interviewed in person (n = 326/395). Mothers were enrolled from the Dr. Sulaiman Al-Habib Hospital (58%), Maternity and Children Hospital (13%), Qatif Central Hospital (8%), community (8%), King Fahad University Hospital (7%), and Imam Abdulrahman Al Faisal Hospital (5%). Seven participants were excluded from the analysis due to the identification of medical conditions that could have interfered with normal feeding, even though these conditions were not prelisted in the exclusion criteria. TableÌý1 shows the demographic and clinical characteristics of the mothers and their children. The distribution of children’s ages at the time of the interviews was relatively balanced, with most children being between 12 and 18 months old, and the majority being born full-term.

Table 1 Characteristics of study participants

Breastfeeding practices

TableÌý2 presents the breastfeeding practices of mothers. Only 25% initiated breastfeeding within one hour of delivery, with most children’s first breastfeeding was delayed beyond two hours. Moreover, 10% of the sampled children did not receive any initial breastfeeding. The reasons for delayed initiation were caesarean section and hospital policies that hinder early breastfeeding (Fig.Ìý1).

Table 2 Breastfeeding practices (N = 395)

Fig. 1

Reason for delaying breastfeeding initiation beyond 11 h after delivery

Most children (65%) received mixed feeding of both breast milk and formula milk in the first six months, while only 25% were exclusively breastfed for six months.

Factors associated with breastfeeding practices

The variables associated with duration of breastfeeding ≥ 6 months in the adjusted logistic regression model were family income, presence of helper at home, living with a husband, delivery mode, and number of children. Mothers with middle income had a less likelihood of breastfeeding for six months or more compared to those with high income (p < 0.01). Additionally, having helper at home and living with a husband were negatively associated with BF duration of months or more. Multiparous mothers were significantly more likely to practice EBF and breastfeed for longer duration compared uniparous mothers (TableÌý3).

Table 3 Factors associated with breast feeding practice variables among infants who received breast feeding

The factors associated with EBF (Only human milk) in the adjusted analysis included maternal employment, family income, and the number of children. Mothers with post graduated education had a significantly higher likelihood (adjusted OR = 4.4) of EBF as compared to those with only a high school education. Middle income families were less likely to practice EBF compared to high income families.

The factors associated with early initiation of BF were gestational age, birthweight, delivery mode and number of children.

The factors associated with early initiation of breastfeeding included gestational age, birth weight, delivery mode, and number of children. Term babies had 5.3 times higher odds of early initiation compared to preterm babies. Normal birth weight infants had 3.3 times greater odds of early initiation compared to those with low birth weight. Additionally, babies born via normal delivery had four times higher odds of early initiation. Multiparous mothers were more likely to breastfeed with early initiation compared to uniparous mothers, with odds of 3.5.

Complementary feeding practices

Description of CFPs

CFPs among the participants are listed in TableÌý4 and compared to the WHO recommendations. The time for introducing solid food varied greatly among the participants; 45% introduced solid food before six months, 42% at six months, and 13% after six months. The majority of the children were introduced to family meals early (before twelve months), while only 11% were introduced to family meals at one year of age. Overall, the participants demonstrated a suboptimal performance in introducing children to family meals at twelve months, giving them finger food at eight months, and avoiding foods that are choking hazards. Additional details regarding the mothers’ CFPs, such as introducing cow’s milk at twelve months, experiences of introducing solid foods, and the effects of the COVID-19 pandemic on child feeding, are available in Supplementary 2.

Table 4 Description of CFP among participants (WHO recommendations)

Factors associated with adherence to the WHO recommendations

Among all the components of CFPs, variations were most noticeable in providing the recommended number of meals and snacks for specific age groups and introducing finger foods at eight months. Several factors examined in this study significantly impacted those practices.

The factors associated with the introduction of solid food at six months in the unadjusted logistic regression analysis included maternal age, maternal employment, and family income; however, no significant factors were found in the adjusted analysis. The number of meals per day, as recommended, was significantly associated with maternal education and family income. Mothers with postgraduate education had 5.6 times the likelihood of following the recommended guidelines compared to those with a high school education. Low-income families were less likely to adhere to the recommended guidelines compared to high-income families. Maternal education also showed a similar association with the recommended level of snacks per day. Additionally, the number of children was significantly associated with the number of snacks consumed per day (see TablesÌý4 and 5).

Table 5 Factors associated with complementary feeding practices (adjusted OR, 95%CI, p value)

FigureÌý2 shows mothers’ adherence to the WHO CFP recommendations. Most mothers did not give their children sugary soft drinks (92%) or tea/coffee (79%). However, only 11% introduced family meals at twelve months, and 22% avoided chocking hazards foods. Commonly reported choking-hazard foods included raw apple, potato chips, grapes, and raw carrots. FigureÌý3 displays a comprehensive list of these high-risk foods.

Fig. 2

Percentage of mother’s adherence to WHO complementary feeding recommendations

Fig. 3

Choking foods given to children ages 6–24 months

In this study, only one participant adhered to all recommended practices. Nearly half (45%) achieved a score of ≥ 5, indicating a good level of CFPs, while 55% scored below 5, indicating a poor CFPs adherence. One received a score of zero, indicating non-adherence to the recommended CFPs (Fig.Ìý4).

Fig. 4

Complementary feeding practices score distribution

Supplementary 3 shows the proportions of children who were given the recommended number of meals and snacks. Younger children were more likely to receive the recommended number of meals compared to older children; however, this was not the case for snacks.

Discussion

Nutrition in early life is vital for long-term health outcomes, including growth, immunity, cognitive function, and chronic diseases prevention. Adhering to the WHO feeding recommendations ensures a healthy foundation. This study aimed to identify factors associated with adherence to the WHO breastfeeding and complementary feeding practice (CFP) recommendations for infants and toddlers.

Interpretation of findings in context

Our study found that only 9.6% of the sampled children had never received human milk, similar to the 9% reported by Amin et al. in the Eastern Province [16]. However, we identified low rates of early breastfeeding initiation and EBF in this region. In contrast, Ahmed and Salih reported that 49% of births in the Eastern Province had early breastfeeding initiation within one hour of delivery in 2019, compared to 24.8% in our sample [3]. This discrepancy could be attributed to sample characteristics, as Ahmed and Salih’s collected data from primary healthcare centres in Dammam, resulting in a more homogenous demographic. In contrast, our sample included participants from various hospitals and community settings. Furthermore, breastfeeding behaviours may have changed between 2019 and our data collection in 2022. It’s also important to note that the rate of caesarean sections was higher in our study (35%) compared to 27% in Ahmed and Salih’s study, which could explain the differences in results. Mothers who deliver through caesarean section often experience delayed initiation of breastfeeding due to separation from the mother during recovery [17]. Prior research in Saudi Arabia, the United Arab of Emirates, Qatar, Lebanon, Iran, and Turkey [3, 18,19,20,21,22,23,24] as well as a systematic review [25] revealed that vaginal delivery was a significant positive predictor for the timely initiation of breastfeeding.

Similarly, our study found low rates of EBF which vary across the country’s regions. For instance, a 2011 study in the Eastern Province (Alhassa) reported an EBF rate of 24% comparable to our study [26]; while the Central Province (Riyadh) had a slightly higher rate of 28% [27]. Southern region (Najran) reported an EFB rate of 32% [28]; all significantly higher than rates found in the Western Province (Jeddah and Taif) 5.3% and 19%, respectively [24, 29] and in the Southwestern Province (Abha) at 8.3% [30]. Internationally, our EBF rate was similar to that in the US which was reported at 25.4% in 2020 by Centres for Disease Control and Prevention [31].

Implications for public health

The present study found that not having a helper increased the duration of breastfeeding. Sociodemographic analysis showed that mothers with postgraduate education were more likely to breastfeed for the first six months compared to those with less education. Additionally, unemployed mothers had a higher rate of EBF than employed mothers, consistent with other study in Saudi Arabia [32]. Our results, along with those of previous research, highlight the need to investigate the reasons for low EBF rates among working mothers. Moreover, studies have shown that normal birthweight and multiparty were significantly associated with higher EBF rates [26, 32, 33], highlighting the importance of education campaigns and policies that ensure low-birth-weight infants who are particularly vulnerable are receive the breast milk they need protect them from complications related to prematurity.

Optimal CFPs are linked to improved short- and long-term outcomes [1]. This study found that only 41.8% of infants received complementary solid food by six months. While this rate is suboptimal in Saudi Arabia, it is higher than in neighbouring countries such as the United Arab Emirates, where only 28% of infants were given solid food before six months [34]. Previous studies indicate improvements over time, although regional differences persist.

Four nationwide nutritional surveys in Saudi Arabia tracked the introduction of complementary food. The 1987surveyfound a mean age of 5.3 months [35], with77% of infants receiving solid foods between three and six months in 1991 [36]. This rate decreased to 51.6% in 1995 [9], but rose to 81% between four and eight months in2004, 2005 and2012 [7, 9]. Overall, CFPs have been inconsistent; only 13% of infants were optimally introduced to solid foods across the five main region [37], while the Western Province had a higher rate of 64.3% [29]. Our study found that older mothers were more likely to introduce solid foods at six months, consistent with Alzaheb’s findings [8]. Additionally, 32%of mothers reported difficulties, primarily because their disliked many foods.

Data suggest that EBF positively predicts the timely introduction of solid foods. European studies have shown that formula-fed infants are given solids earlier than breastfed infants [38, 39]. However, our study found no association between exclusivity and the introduction of complementary food.

A significant proportion of children in this study received recommended number of meals. Younger infants (6–8 months) were more likely to meet meal recommendations but less likely to receive the recommended number of meals compared to older children. In contrast, a study in Ethiopia found that only 47% of mothers provided the minimum meal frequency [40].

Healthy family meals should be gradually introduced starting at twelve months, while the use of commercial baby foods should be minimized to prevent delays in accepting family food [41]. When introducing family meals, it’s important to limit salt and processed food, as infants aged twelve months to three years should have a sodium intake no greater than 1200Ìýmg to prevent chronic diseases. A previous study found that most children with higher sodium intake consumed processed foods [42].

The current study observed that merely 11% of children were introduced to family meals at twelve months. Previous research found, switching from spoon-feeding to baby-led feeding increased family food acceptance and provided developmental benefits. Self-feeding can be assisted by giving the baby finger foods, which should be introduced by eight months of age. In this study, only 44% of infants were given finger foods by eight months, significantly lower than the 90%reported in a UK study [43]. Additionally, our findings indicated that higher monthly family income is significantly associated with certain complementary feeding practices (CFPs), including the introduction of family meals and finger foods.

Most children in this study were fed at least one of common foods that pose a high choking risk [14]., a finding that warrants an intervention to avoid the health risks associated with choking among children.

To our knowledge, no previous studies have examined the introduction of tea, coffee, and soft drinks in Saudi Arabia. This practice is not recommended, and mothers’ should be made aware of the associated risks. In our study, 21.5% of mothers did not adhere to the recommendation to avoid these drinks. Similarly, while introducing fruit juices to children is not recommended, some children in this study were given fruit juices, consistent with findings from Ahmed and Salih [37].

This study also assessed the adherence to CFPs among the participating mothers using a scoring method. Notably, only one mother adhered to all nine recommended CFPs. About half of the remaining mothers scored ≥ 5, meaning good practices. Previous studies in Saudi Arabia also highlighted a gap between prevailing and recommended practices [29, 37]. Similarly, studies conducted in Ethiopia [40, 44], Pakistan [45], and Italy [46] reported low levels of adherence to appropriate CFPs.

Strength and limitations

The strengths of our study include a large sample size and the use of in-person interviews for data collection, which provide more robust responses and deeper insights compared to self-reported data. No data were gathered through online surveys. Additionally, both breastfeeding and complementary feeding practices (CFPs) were thoroughly investigated, and data were collected from multiple sources, enhancing reliability and generalizability. However, the study has several limitations. A significant drawback is the retrospective nature of the data collection, which may introduce recall bias. Another limitation is the lack of diversity in sociodemographic, as more than half of the responses were obtained from mothers attending one private hospital. The third limitation is the use of a convenience sampling method, which may be susceptible to self-selection bias. Due to geographical proximity, availability, and willingness to participate, it was challenging to implement cluster or stratified sampling from each primary health centre; thus, we opted for convenience sampling. Future studies should employ large-scale designs using cluster or stratified sampling techniques for better representation.

As this is an observational study, several types of potential bias may exist. To minimize communication bias, data collectors used standardized questionnaires and underwent training to ensure clear instructions were provided to participants. Recall bias could also be a concern, especially regarding breastfeeding initiation for mothers of two-year-old children. To mitigate this risk, the questionnaire included clear, specific questions with defined time frames, such as the initiation and duration of breastfeeding and the timing of introducing solid foods. Additionally, collecting data through interviews likely helped mothers recall information more accurately.

The distribution of children’s age categories was relatively balanced; however, 79% of the children were toddlers. Consequently, the generalizability of the results should be interpreted with caution due to the lack of stratification in the sampling technique. Finally, we did not identify the specific age of initiation of complementary food for infants introduced to solids after six months. Further research is needed to clarify this timing.

Conclusion

This study highlights partial compliance with WHO guidelines for complementary feeding practices in the Eastern Province of Saudi Arabia. Factors influencing feeding practices include maternal employment and education level.

Breastfeeding initiation within one hour of birth, EBF, and CFPs appear to be lower than in other regions of Saudi Arabia. Collaborative efforts maybe beneficial, such as supporting breastfeeding through female employment policies and implementing nutritional education campaigns. Healthcare centres and hospitals might consider adopting feeding policies to promote better nutrition for infants and young children. The findings suggest a need for improved awareness on CFPs among mothers and caregivers through targeted education. Evidence-based recommendations from this study are summarised in Box 2.

Box 2 Recommended strategies for promoting optimal infant and toddler feeding