INDICATORS OF CHILD FEEDING

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INDICATORS FOR ASSESSING INFANT AND YOUNG CHILD
FEEDING PRACTICES
Conclusions of a consensus meeting
held 6-8 November 2007 in
Washington D.C., USA
INTRODUCTION
It has been 16 years since the publication of the document Indicators for assessing breastfeeding
practices (1), which provided a set of indicators that could be used to assess infant feeding within
and across countries and evaluate the progress of breastfeeding promotion efforts. Since 1991, there
have been important developments in infant and young child feeding recommendations and
scientific knowledge about what constitutes optimal breastfeeding and complementary feeding
practices, which have led to the need for revision and expansion of the set of indicators initially
recommended. In 2001, for example, the World Health Organization (WHO) recommended
exclusive breastfeeding for 6 months (2, 3), which was a change from the previous recommendation
to introduce complementary foods at 4-6 months. The indicator for exclusive breastfeeding from 0-4
months thus no longer provides data reflective of current guidelines.
In addition, the document published in 1991 included only one indicator of complementary feeding
– the timely complementary feeding rate. This indicator provided information about whether
complementary foods were consumed, but not about the quantity or quality of those foods. In
response to concerns about the lack of adequate indicators of complementary feeding, in 2002,
WHO began a process to review and develop indicators of complementary feeding practices. A
conceptual framework for identifying potential indicators of complementary feeding practices was
published (4). At the same time, the Guiding Principles for Complementary Feeding of the
Breastfed Child were being developed, which addressed the multidimensionality of complementary
feeding practices (5). A similar effort to develop guidance and rationale for feeding non-breastfed
children 6-24 months of age was undertaken shortly thereafter, which resulted in a technical
document (6) and a parallel set of Guiding Principles (7). Beginning in 2004, members of the
Working Group on Infant and Young Child Feeding Indicators initiated a series of activities aimed
toward definition and validation of indicators to reflect dietary quality and quantity, using existing
data sets from 10 different sites in developing countries (members of the Working Group are listed
in Annex 1a). In addition to using the references listed above as guidance, the Working Group was
also guided by the recommendations and targets of the Global Strategy for Infant and Young Child
Feeding (8). The results of the analyses conducted by the Working Group were summarized in a
report in the summer of 2006 (9) and presented at a WHO consultation in October, 2006. Additional
analyses to address the remaining questions and concerns were subsequently completed and
described in a report submitted in the summer of 2007 (10).
Based on the above work, a revised set of indicators was developed and then discussed by
participants at the WHO Global Consensus Meeting on Indicators of Infant and Young Child
Feeding held from 6-8 in November, 2007 on the premises of the WHO Regional Office for the
Americas. The list of participants is provided in Annex 1b. This report summarizes the discussion
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and consensus reached on 8 core indicators and 7 optional indicators for assessing infant and young
child feeding that are population-based and can be derived from household survey data.
A. PURPOSE OF THE INDICATORS
Infant and young child feeding practices directly affect the nutritional status of children under two
years of age and, ultimately, impact child survival. Improving infant and young child feeding
practices in children 0 - 23.9 months of age is therefore critical to improved nutrition, health and
development of children. However, until now, indicators that can be used in population-based
surveys to measure infant and young child feeding practices have focused mostly on breastfeeding
practices. The lack of evidence and consensus on simple indicators of appropriate feeding practices
in children 6 - 23.9 months of age has hampered progress in measuring and improving feeding
practices, thereby constraining improvements in infant and young child nutritional outcomes.
The indicators described in this document are the result of a 5-year effort to develop a set of simple,
valid and reliable population-level indicators to assess infant and young child feeding practices.
Population-level indicators of infant and young child feeding practices are used primarily for: (1)
assessment: to make national and sub-national comparisons and to describe trends over time; (2)
targeting: to identify populations at risk, target interventions, and make policy decisions about
resource allocation; and (3) monitoring and evaluation: to monitor progress in achieving goals and
to evaluate the impact of interventions.
The indicators described herein are mainly designed for use in large-scale surveys or national
programs. Smaller local and regional programs may also find uses for these indicators, but this
limited set of measures is not intended to meet all of the needs for program monitoring and
evaluation at this level. Programs and projects should augment these with more specific indicators
that reflect their own interventions, messages, and behavior change objectives. Also, inasmuch as
the sample sizes used in monitoring and evaluation of smaller scale programs may be quite small,
some of the recommended indicators may be too imprecise to be of use in assessment or in
monitoring change. This is particularly likely for indicators with narrow age ranges in the numerator
and the denominator.
B. METHODOLOGY FOR MEASURING INDICATORS
The proposed indicators should be derived from interviews conducted at the household level using a
household survey methodology. Although the age group used for each indicator will vary, most
indicators can be generated using data from living children less than 24 months of age1. Deceased
children are generally not included in the indicator calculations (with the exception of the indicators
“children ever breastfed” and “early initiation of breastfeeding”). Once core and optional indicators
are selected as described below, the survey should be designed to provide adequate sample sizes for
all age sub-groups of interest. Except for the indicators “children ever breastfed” and “early
initiation of breastfeeding”, all indicators are based on current status data, i.e., the current age of the
child and other information for the day preceding the survey, rather than on retrospective data.
Mothers will not be asked when they stopped or started particular feeding practices, which are
questions that tend to produce a heaping of data at certain ages. The previous-day recall period was
1 The optional indicator 'median duration of breastfeeding' requires a broader range of children up to 36 months of age.
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selected because it has been widely used and found appropriate in surveys of dietary intake when the
objective is to describe infant feeding practices in populations. Because practices vary widely from
day to day, indicators derived from the previous day recall period should not be used to make
assessments of dietary adequacy at the level of the individual.
Criteria for selected feeding practices used for the definitions of some of the indicators are shown in
Table 1. A child can be classified as following a certain practice if criteria listed for that practice are
met. Relative to the 1991 guidance, one modification was made with regard to the criteria for
exclusive breastfeeding. Since ORS is a medicine, it was agreed to allow this under the definition of
exclusive breastfeeding. Exclusive breastfeeding now means that the infant receives breastmilk
(including expressed breastmilk or breastmilk from a wet nurse) and allows the infant to receive
ORS, drops, syrups (vitamins, minerals, medicines), but nothing else.
Table 1: Criteria for selected infant feeding practices used for the indicators
Feeding
practice
Requires that the infant
receive
Allows the infant to
receive
Does not allow
the infant to
receive
Exclusive
breastfeeding
Breastmilk (including
milk expressed or from a
wet nurse)
ORS, drops, syrups
(vitamins, minerals,
medicines)
Anything else
Predominant
breastfeeding
Breastmilk (including
milk expressed or from a
wet nurse) as the
predominant source of
nourishment
Certain liquids (water and
water-based drinks, fruit
juice), ritual fluids and
ORS, drops or syrups
(vitamins, minerals,
medicines)
Anything else (in
particular, nonhuman
milk,
food-based fluids)
Complementary
feeding2
Breastmilk (including
milk expressed or from a
wetnurse) and solid or
semi-solid foods
Anything else: any food or
liquid including nonhuman
milk and formula
NA
Breastfeeding Breastmilk (including
milk expressed or from a
wet nurse)
Anything else: any food or
liquid including nonhuman
milk and formula
NA
Bottle-feeding Any liquid (including
breastmilk) or semi-solid
food from a bottle with
nipple/teat
Anything else: any food or
liquid including nonhuman
milk and formula
NA
2 The term complementary feeding is no longer used in the indicators to assess infant and young child feeding practices.
The previously used indicator 'Timely complementary feeding rate' (1), which combined continued breastfeeding with
consumption of solid, semi-solid and soft foods, was difficult to interpret. This indicator has therefore been replaced by
the indicator 'Introduction of solid, semi-solid or soft foods' which is a measure of a single feeding practice.
Nevertheless, the term complementary feeding is still very useful to describe appropriate feeding practices in children 6 -
23.9 mo of age and will continue to be used in programmatic efforts to improve infant and young child feeding as guided
by the Global Strategy on Infant and Young Child Feeding (8).
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C. DEFINITIONS OF INDICATORS
The key indicators are defined and explained below. A summary list of the indicators is presented in
Annex 2. For certain indicators, it is strongly recommended that figures (or area graphs) be created
to depict the changes in the proportions of children with each of the relevant feeding practices by
child age. Examples of such figures are given in Annex 3.
CORE INDICATORS:
Breastfeeding initiation
1. Early initiation of breastfeeding: Proportion of children born in the last 23.9 months who were
put to the breast within one hour of birth
Children born in the last 23.9 months who were put to the breast within one hour of birth
Children born in the last 23.9 months
Note 1: This indicator is based on historic recall. The denominator and numerator include living
children and deceased children who were born within the past 23.9 months.
Note 2: It is recommended that the indicator be further disaggregated and reported for (i) live
births occurring in the last 11.9 months; and (ii) live births occurring between the last 12 and
23.9 months.
Exclusive breastfeeding
2. Exclusive breastfeeding under 6 months: Proportion of infants 0-5.9 months of age who are
fed exclusively with breastmilk
Infants 0-5.9 months of age who received only breastmilk during the previous day
Infants 0-5.9 months of age
Note 1: This indicator includes breastfeeding by a wet nurse and feeding expressed breastmilk. It
was, however, thought simpler to retain the term "exclusive breastfeeding" rather than the more
precise but cumbersome term "fed exclusively on breastmilk". (For the definition of "exclusive
breastfeeding" see Table 1.)
Note 2: This is the first in the series of current status indicators based on recall of the previous
day and includes living infants. All indicators that follow are also based on recall of the previous
day.
Note 3: Using the previous day recall period will cause the proportion of exclusively breastfed
infants to be overestimated, as some infants who are given other liquids irregularly may not have
received them in the day before the survey.
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Note 4: As with other indicators that are based on current status, exclusive breastfeeding is based
on a cross section of children in a given age range, in this case children 0 - 5.9 months of age. It
does therefore not represent the proportion of infants that are exclusively breastfed until 6
months of age and should not be interpreted as such. It is generally accepted that the proportion
of children that are exclusively breastfed until 6 month of age is lower than the number derived
from the indicator of current status. However, the indicator recommended in this document
represents the best option for estimating exclusive breastfeeding and is more sensitive to
capturing changes. If there is interest in identifying differences in proportions exclusively
breastfed over smaller age ranges, creation of a figure such as shown in Annex 3, and
disagregation as suggested under Note 5, may provide such information.
Note 5: It is recommended that the indicator be further disaggregated and reported for the
following age-groups: 0-1.9 months, 2-3.9 months, 4-5.9 months and 0-3.9 months.
Continued breastfeeding
3. Continued breastfeeding at 1 year: Proportion of children 12 – 15.9 months of age who are fed
breastmilk
Children 12-15.9 months of age who received breastmilk during the previous day
Children 12-15.9 months of age
Note 1: This indicator includes breastfeeding by a wet nurse and feeding expressed breastmilk
Note 2: The title of this indicator on continued breastfeeding reflects an approximation of the
age range covered.
Note 3: Because the indicator has a relatively narrow age range of 4 months, the estimates from
surveys with small sample sizes are likely to have wide confidence intervals.
Introduction of complementary foods
4. Introduction of solid, semi-solid or soft foods: Proportion of infants 6-8.9 months of age who
receive solid, semi-solid or soft foods
Infants 6-8.9 mo of age who received solid, semi-solid or soft foods during the previous day
Infants 6-8.9 months of age
Note 1::This indicator is one of the two parts of the previous composite indicator for timely
complementary feeding, which also included continued breastfeeding.
Note 2: The previous indicator included living infants 6-9.9 months in the numerator and
denominator. A narrower age range has been chosen so as not to include infants receiving foods
as late as 9-9.9 months in the numerator.
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Note 3: Because the indicator has a very narrow age range of 3 months, the estimates from
surveys with small sample sizes are likely to have wide confidence intervals.
Dietary diversity
5. Minimum dietary diversity: Proportion of children 6-23.9 months of age who receive foods
from 4 or more food groups
Children 6-23.9 mo of age who received foods from G 4 food groups during the previous day
Children 6-23.9 months of age
Note 1 : The 7 foods groups used for tabulation of this indicator are:
- grains, roots and tubers
- legumes and nuts
- dairy products (milk, yogurt, cheese)
- flesh foods (meat, fish, poultry and liver/organ meats)
- eggs
- vitamin-A rich fruits and vegetables
- other fruits and vegetables
Note 2: Consumption of any amount of food from each food group is sufficient to “count”, i.e.,
there is no minimum quantity.
Note 3: This indicator, consumption of foods from at least 4 of the above 7 food groups on the
previous day, would mean that in most populations the child had a high likelihood of
consuming at least one animal-source food and at least one fruit or vegetable that day, in
addition to a staple food (grain, root or tuber).
Note 4: It is recommended that the indicator be further disaggregated and reported for the
following age groups: 6-11.9 months, 12-17.9 months and 18-23.9 months.
Meal frequency
6. Minimum meal frequency: Proportion of breastfed and non-breastfed children 6-23.9 months
of age who receive solid, semi-solid, or soft foods (but also including milk feeds for nonbreastfed
children) the minimum number of times or more
The indicator is calculated from the following two fractions:
Breastfed children 6-23.9 mo of age who received solid, semi-solid or soft foods
the minimum number of times or more during the previous day
Breastfed children 6-23.9 months of age
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and
Non-breastfed children 6-23.9 mo of age who received solid, semi-solid or soft foods or milk feeds
the minimum number of times or more during the previous day
Non-breastfed children 6-23.9 months of age
Note 1: Minimum is defined as:
- 2 times for breastfed infants 6-8.9 months
- 3 times for breastfed children 9 -23.9 months
- 4 times for non-breastfed children 6-23.9 months
"Meals” include both meals and snacks (other than trivial amounts), and frequency is
based on caregiver report.
Note 2: It is recommended that the indicator be further disaggregated and reported for the
following age groups: 6-11.9 months, 12-17.9 months and 18-23.9 months of age.
Summary infant and young child feeding indicator
7. Minimum acceptable diet: Proportion of children 6-23.9 months of age who receive a
minimum acceptable diet (apart from breastmilk).
This composite indicator will be calculated from the following two fractions:
Breastfed children 6-23.9 months of age who had at least the minimum dietary diversity and
the minimum meal frequency during the previous day
Breastfed children 6-23.9 months of age
and
Non-breastfed children 6-23.9 months of age who received at least 2 milk feedings and had
at least the minimum dietary diversity
and the minimum meal frequency during the previous day
Non-breastfed children 6-23.9 months of age
Note 1: See indicators 7 and 8 above for "Minimum dietary diversity" and "Minimum meal
frequency" definitions.
Note 2: It is recommended that the indicator be further disaggregated and reported for the
following age groups: 6-11.9 months, 12-17.9 months and 18-23.9 months of age.
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Consumption of iron-rich or iron-fortified foods
8. Consumption of iron-rich or iron-fortified foods: Proportion of children 6-23.9 months of age
who receive an iron-rich food or iron-fortified food that is specially designed for infants and
young children, or that is fortified in the home.
Children 6-23.9 months of age who received an iron-rich food
or a food that was specially designed for infants and young children and was fortified with iron,
or a food that was fortified in the home with a product that included iron during the previous day
Children 6-23.9 months of age
Note 1: Suitable iron-rich or iron-fortified foods include flesh foods, commercially fortified
foods specially designed for infants and young children which contain iron, or foods fortified in
the home with a micronutrient powder containing iron or a lipid-based nutrient supplement
containing iron. Consumption of any amount of food from these categories is sufficient to
“count”, i.e., there is no minimum quantity.
Note 2: It is recommended that the indicator be further disaggregated and reported for the
proportion of children receiving flesh foods only and the proportion of children who consume
some fortified food specially designed for infants and young children which contains iron (with
or without flesh foods)
Note 3: It is also recommended that the indicator be further disaggregated and reported for the
following age groups: 6-11.9 months, 12-17.9 months and 18-23.9 months of age.
OPTIONAL INDICATORS:
Considering the need to limit the number of indicators and quantity of data to be collected to a
minimum, it is proposed that the indicators described above are the most critical for populationbased
assessment and programme evaluation. However, to ensure continuity in monitoring of
previously used indicators and recognizing that some programmes may wish to measure additional
indicators, the following optional indicators are recommended:
Breastfeeding
9. Children ever breastfed: Proportion of children born in the last 23.9 months who were ever
breastfed
Children born in the last 23.9 months who were ever breastfed
Children born in the last 23.9 months
Note: This indicator is based on historic recall. The denominator and numerator include living
and deceased children who were born within the past 23.9 months.
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Note 2: It is recommended that the indicator be further disaggregated and reported for (i) live
births occurring in the last 11.9 months; and (ii) live births occurring between the last 12 and
23.9 months .
10. Continued breastfeeding at 2 years: Proportion of children 20 – 23.9 months of age who are
fed breastmilk
Children 20-23.9 months of age who received breastmilk during the previous day
Children 20-23.9 months of age
Note 1: The title of this indicator on continued breastfeeding reflects an approximation of the
age range covered.
Note 2: Because the indicator has a relatively narrow age range of 4 months, the estimates from
surveys with small sample sizes are likely to have wide confidence intervals.
11. Age-appropriate breastfeeding: Proportion of children 0-23.9 months of age who are
appropriately breastfed
The indicator is calculated from the following two fractions:
Infants 0-5.9 months of age who received only breastmilk during the previous day
Infants 0-5.9 months of age
and
Children 6-23.9 months of age who received breastmilk, as well as solid, semi-solid or soft foods,
during the previous day
Children 6-23.9 months of age
12. Predominant breastfeeding under 6 months: Proportion of infants 0 – 5.9 months of age who
are predominantly breastfed
Infants 0-5.9 months of age who received breastmilk
as the predominant source of nourishment during the previous day
Infants 0-5.9 months of age
Note 1: As the proportion of infants exclusively breastfed up to 6 months may be quite low in
some populations, the intent of this indicator is to identify infants whose predominant source of
nourishment is breastmilk, but who also receive other fluids.
Note 2: Predominant breastfeeding means that the infant receives breastmilk (including
expressed breastmilk or breastmilk from a wet nurse) and allows the infant to receive certain
liquids (water and water-based drinks, fruit juice, ritual fluids), ORS, drops, or syrups (vitamins,
minerals, medicines), but nothing else. No non-human milks or food-based fluids are allowed.
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Note 3: An area graph as illustrated in Annex 3 is the clearest illustration of various infant
feeding practices and when used, can replace this indicator.
Duration of breastfeeding
13. Duration of breastfeeding: Median duration of breastfeeding among children 0-35.9 months of
age
The age in months when 50% of children 0-35.9 mo did not receive breastmilk during the previous
day
Note: The population median duration of breastfeeding is the only indicator that requires
collection of data on feeding practices in children above 24 months of age and is calculated
using current status data among all children less than 36 months of age. Table 2 in Annex 5
illustrates the calculation of the population median duration of breastfeeding.
Bottle feeding of infants
14. Bottle feeding: Proportion of children 0-23.9 months of age who are fed with a bottle.
Children 0-23.9 months of age who were fed with a bottle during the previous day
Children 0-23.9 months of age
Note 1: Information on bottle feeding is useful because of the potential interference of bottle
feeding with optimal breastfeeding practices and the association between bottle feeding and
increased diarrhoeal disease morbidity and mortality. Bottles with a nipple are particularly prone
to contamination. Included in the numerator of this indicator are children less than 23.9 months
of age who received any food or drink from a bottle with a nipple/teat during the previous day
(including breast milk), regardless of whether or not the infant was breastfed.
Note 2: It is recommended that this indicator be further disaggregated and reported for each of 3
age groups: 0-5.9 months, 6-11.9 months and 12-23.9 months.
Milk feeding frequency for non-breastfed children
15. Milk feeding frequency for non-breastfed children: Proportion of non-breastfed children 6-
23.9 months of age who receive at least 2 milk feedings
Non-breastfed children 6-23.9 months of age
who received at least 2 milk feedings during the previous day
Non-breastfed children 6-23.9 months of age
Note 1: Milk feedings include liquid milk products such as infant formula, cow milk or other
animal milk. The specific products to be included need to be defined for each target population,
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to take into account local milk products that are commonly fed to young children in substantial
quantities (e.g. fermented dairy products).
The minimum of 2 milk feedings was selected based on the following: Average energy intake
from breast milk in developing countries is approximately 400 kcal/day at 6-11 months and 350
kcal/day at 12-23 months (5). For non-breastfed children, the dietary analysis results (9)
indicated that 3 milk feedings per day would generally allow for an average intake of milk that is
similar to this range (300-400 kcal from milk). Most children will probably not consume more
than 180-240 mL of milk per feed, which would be equivalent to ~100-150 kcal/feed if
consumed as liquid whole cow milk. Taking the upper end of this range (150 kcal/feed) and a
slightly lower “target” for energy intake from milk than is consumed by breastfed children (300
kcal/day), a minimum of 2 milk feedings per day would be needed.
Note 2: It is recommended that the indicator be further disaggregated and reported for the
following age groups: 6-11.9 months, 12-17.9 months and 18-23.9 months.
D. OPERATIONALIZING THE INDICATORS
Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and
Knowledge, Practice and Coverage (KPC) Surveys are important sources of information on infant
and young child feeding practices for many countries. Based on a comparison of the proposed
indicators and comparable indicators that are currently (up to November 2007) used in these
surveys, participants identified and discussed a number of methodological differences in
measurement between the various surveys. While secondary analyses of selected differences
indicated that this might not lead to significantly different results, it was nevertheless considered
critical to work towards further harmonization of methodologies for measuring the indicators. It was
thus agreed to constitute a working group of measurement experts to develop an operational guide to
complement this document. The guide will include questions to elicit information and address
methodological issues related to sampling. It will also include a table comparing the core and
additional indicators listed in this document with indicators used in DHS, MICS and KPC up to the
point of the meeting. The operational guide will be available as a published document from the
partner agencies that have contributed to this publication.
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REFERENCES
1. WHO. Indicators for assessing breastfeeding practices. WHO/CDD/Ser/91.14. Geneva:
World Health Organization, 1991.
2. WHO. The optimal duration of exclusive breastfeeding. Report of an Expert Consultation.
Geneva, World Health Organization, 2001.
3. WHO. Infant and young child nutrition. Geneva, Switzerland: World Health Organization;
18 May 2001. Resolution 54.2.
4. Ruel, M. T., K. H. Brown, and L. E. Caulfield. “Moving Forward with Complementary
Feeding: Indicators and Research Priorities.” Food and Nutrition Bulletin 24 (2003) (3): 289-
90 and IFPRI/FCND Discussion Paper, April 2003.
5. PAHO/WHO. Guiding Principles for Complementary Feeding of the Breastfed Child.
Washington, D.C: Pan American Health Organization, 2003.
6. Dewey, K. G., R. J. Cohen, and N. C. Rollins. “Feeding of Non-Breastfed Children 6-24
Months of Age in Developing Countries.” Food and Nutrition Bulletin 25 (2004): 377-402.
7. WHO. Guiding Principles for Feeding Non-Breastfed Children 6-24 Months of Age. Geneva:
World Health Organization, 2005.
8. WHO/UNICEF. Global Strategy on Infant and Young Child Feeding. Geneva, Switzerland:
World Health Organization, 2003.
9. Working Group on Infant and Young Child Feeding Indicators. Developing and Validating
Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in
Developing Countries: Summary of findings from analysis of 10 data sets. Report submitted
to: the Food and Nutrition Technical Assistance (FANTA) Project/Academy for Educational
Development (AED), August 2006.
10. Working Group on Infant and Young Child Feeding Indicators. Developing and Validating
Simple Indicators of Dietary Quality of Infants and Young Children in Developing
Countries: Additional analysis of 10 data sets. Report submitted to: the Food and Nutrition
Technical Assistance (FANTA) Project/Academy for Educational Development (AED), July
2007
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Annex 1a
Members of the Working Group on Infant and Young Child Feeding Indicators
The Working Group on Infant and Young Child Feeding Indicators was constituted in December
2002, following an informal meeting organized by WHO and hosted at the WHO Regional Office of
the Americas. The Working Group had a permanent Steering Team and a large number of
contributors who participated in various tasks. Principal investigators were responsible for data
analysis from 10 sites that generated the evidence base for formulation of new indicators for
children 6-23.9 months of age. Additional analysis was conducted at the International Food Policy
Research Institute (9, 10).
Members of the Steering Team were:
Mary Arimond and Marie Ruel at the Food Consumption and Nutrition Division of the
International Food Policy Research Institute. Washington, D.C.
Kathryn Dewey at the Program in International and Community Nutrition of the University
of California, Davis
Eunyong Chung at the United States Agency for International Development (USAID)
Anne Swindale at the Food and Nutrition Assistance (FANTA) Project of the Academy for
Educational Development, Washington, D.C.
Chessa Lutter at the Unit on Child and Adolescent Health of the WHO Regional Office for
the Americas, Washington D.C.
André Briend, Bernadette Daelmans, and José Martines at the Department for Child and
Adolescent Health and Development of the World Health Organization, Geneva
Principal investigators involved in the 10-site analysis were:
Cecilia C. Santos-Acuin, Institute of Clinical Epidemiology, National Institutes of Health,
University of the Philippines, Manila, (Philippines);
Nita Bhandari, Society for Applied Studies, New Delhi, (India);
Hilary Creed de Kanashiro, Instituto de Investigación Nutricional, Lima, (Trujillo, Peru);
Roberta Cohen and Kathryn Dewey, UC-Davis (Bangladesh; Ghana; Honduras; Huascar,
Peru);
Christine Hotz, HarvestPlus (Malawi);
Mourad Moursi, Institute of Research for Development, Montpellier (Madagascar);
Helena Pachon, International Center for Tropical Agriculture, Cali (Brazil).
An informal working group to update breastfeeding indicators was constituted in June 2007 and led
by Chessa Lutter (Pan American Health Organization, World Health Organization). Other members
of the informal working group were: Mary Arimond at IFPRI; Kathryn Dewey at UC Davis; Megan
Deitchler at FANTA; Rae Galloway at the Infant and Young Child Nutrition (IYCN) Project,
Monica Kothari at Macro International; Moazzem Hossein, Attila Hancioglu, Julia Krasevec, Nune
Mangasaryan and Tessa Wardlaw at UNICEF; Andre Briend, Bernadette Daelmans, Chika Hayashi,
Peggy Henderson, Randa Saadeh, and Constanza Vallenas at WHO.
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Annex 1b
List of Participants at the Global Consensus Meeting on
Indicators for Infant and Young Child Feeding
6 - 8 November, 2007
Washington, D.C.
Mandana Arabi
Health and Nutrition Section
UNICEF
New York, USA
Mary Arimond
Food Consumption and Nutrition Division
International Food Policy Research Institute
Washington, D.C., USA
Eunyong Chung
Division of Nutrition
USAID, GH/HIDN/NUT
Washington, D.C., USA
Hilary Creed de Kanashiro
Instituto de Investigacion Nutricional
Lima, Peru
Megan Deitchler
Food and Nutrition Assístance (FANTA)
Project
Academy for Educational Development
Washington, D.C., USA
Kathryn Dewey
Program in International and Community
Nutrition
University of California
Davis, USA
Nadra Franklin
Academy for Educational Development
Washington, D.C., USA
Alfredo Fort
Demographic and Health Surveys
Macro International
Calverton, USA
Rae Galloway
Infant and Young Nutrition Project
PATH
Washington, D.C., USA
Agnès Guyon
Academy for Educational Development
Washington, D.C., USA
Attila Hancioglu
Statistics and Monitoring Section
UNICEF
New York, USA
Julia Krasevec
Health and Nutrition Section
UNICEF
New York, USA
Miriam Labbok
Department of Maternal and Child Health,
School of Public Health
University of Carolina
Chapel Hill, USA
Alice Morton
Infant and Young Child Nutrition (IYCN)
Project
PATH
Washington, D.C., USA
Holly Newby
Statistics and Monitoring Section
UNICEF
New York, USA
15
Ellen Piwoz
Integrated Health Solutions Development
Bill and Melinda Gates Foundation
Seattle and Washington, D.C., USA
Marie Ruel
Food Consumption and Nutrition Division
International Food Policy Research Institute
Washington, D.C., USA
Shea Rutstein
Demographic and Health Surveys
Macro International
Calverton, USA
Anne Swindale
Food and Nutrition Assístance (FANTA)
Project
Academy for Educational Development
Washington, D.C., USA
Alison Tumilowicz
Food and Nutrition Assístance (FANTA)
Project
Academy for Educational Development
Washington, D.C., USA
WHO Secretariat
Bernadette Daelmans
Department of Child and Adolescent Health
and Development
World Health Organization
Geneva, Switzerland
Chessa Lutter
Unit on Child and Adolescent Health
WHO Regional Office for the Americas
Pan American Health Organization
Washington, D.C. USA
José Martines
Department of Child and Adolescent Health
and Development
World Health Organization
Geneva, Switzerland
Randa Saadeh
Department of Nutrition for Health and
Development
World Health Organization
Geneva, Switzerland
Camila Chaparro
Unit on Child and Adolescent Health
WHO Regional Office for the Americas
Pan American Health Organization
Washington, D.C. USA
16
Annex 2
Summary List of Indicators
Core Indicators
1. Early initiation of breastfeeding
2. Exclusive breastfeeding under 6 months
3. Continued breastfeeding at 1 year
4. Introduction of solid, semi-solid foods or soft foods
5. Minimum dietary diversity
6. Minimum meal frequency
7. Minimum acceptable diet
8. Consumption of iron-rich or iron-fortified foods
Optional Indicators
9. Children ever breastfed
10. Continued breastfeeding at 2 years
11. Age-appropriate breastfeeding
12. Predominant breastfeeding under 6 months
13. Duration of breastfeeding
14. Bottle-feeding
15. Milk feeding frequency for non-breastfed children
Top priorities for reporting among the core indicators
Since it may not always be feasible to report on all core indicators, the following four indicators are
recommended in order of priority for two critical age groups, based on evidence of their positive
association with child survival and/or nutrient intakes.
To assess breastfeeding practices in infants:
1. Exclusive breastfeeding under 6 months
2. Early initiation of breastfeeding
To assess feeding practices in children 6 - 23.9 months of age:
1. Minimum acceptable diet
2. Consumption of iron-rich or iron-fortified foods
17
Annex 3
Examples of figures illustrating infant feeding practices by age group
Percentage of infants exclusively breastfed (EBF) and
percentage receiving solid or semi-solid foods
1 2 3 4 5 6 7 8 9 10 11 12
0
10
20
30
40
50
60
70
80
90
100
Age (mo)
%
EBF Solids
Infant Feeding Practices by Age
0%
20%
40%
60%
80%
100%
0-1
2-3
4-5
6-7
8-9
10-11
12-13
14-15
16-17
18-19
20-21
22-23
24+
Age groups in months Percentage
Exclusively breastfed Breastmilk and plain water only
Breastmilk and non-milk liquids Breastmilk and other milk/formula
Breastmilk and complementary foods Not receiving any breastmilk
18
Annex 4
Overestimation of exclusive breastfeeding rates among infants 0 - 5.9 months of age
(Analysis by KG Dewey & JM Peerson)
The indicator to assess the practice of exclusive breastfeeding (EBF) among children 0-5.9 mo of
age overestimates the actual proportion of infants who are exclusively breastfed until 6 mo. It is
generally accepted that the proportion of children that are breastfed exclusively until 6 months of
age is lower than the number derived from the indicator of current status. This is because the
indicator is based feeding practices received by all infants from 0 to 5.9 mo of age, so many who are
still exclusively breastfed at younger ages may no longer be exclusively breastfed by the time they
reach 6 mo of age.
To evaluate the degree of overestimation, 4 different hypothetical scenarios were defined. The first
set of “simulations” assumed 100% EBF at 0 mo and 20% EBF at 6 mo (e.g. 180 days).
Scenario Prevalence EBF 0-5.9 mo Actual EBF at 6 mo3
1) Linear rate of decline in EBF between 0
and 6 mo, from 100% to 20%
60% 20%
2) Slight decline from 100% to 80% EBF
between 0 and 4 mo, then sharp decline to
20% at 6 mo
77% 20%
3) No decline until 5 mo, then sharp
decline to 20%
93% 20%
4) Sharp decline in first month, from 100%
to 40%, then gradual decline to 20% at 6
mo
37% 20%
The second set of “simulations” assumed 80% EBF at 0 mo and 40% EBF at 6 mo (e.g. 180 days).
Scenario Prevalence EBF 0-5.9 mo Actual EBF at 6 mo
1) Linear rate of decline in EBF between 0
and 6 mo, from 80% to 40%
60% 40%
2) Slight decline from 80% to 70% EBF
between 0 and 4 mo, then sharp decline to
40% at 6 mo
68% 40%
3) No decline until 5 mo, then sharp
decline to 40%
77% 40%
4) Sharp decline in first month, from 80%
to 50%, then gradual decline to 40% at 6
mo
48% 40%
Both set of simulations illustrate that the degree of overestimation depends on the infant feeding
practices of the survey population.
3 Simulation for 'Actual EBF at 6 mo' are based on point-estimates
19
Annex 5
Calculation of population median duration of breastfeeding
The first step in the calculation is to determine the proportion of all living children in each singlemonth
age group who are still breastfed. The next step is to smooth these data by calculating a 3-
month moving average. The population median duration of breastfeeding is the month of age when
50% or more of the children are no longer breastfed.
While the other indicators can be derived from information from children under 24 months, the
median duration of breastfeeding should be based on data from children under 36 months, especially
in countries and among population subgroups where the median duration of breastfeeding is close to
24 months. If data are available only for children under 24 months of age, and if more than 50% of
the children are still breastfed at 24 months of age, the median duration could be expressed as
"longer than 24 months". However, an indicator calculated this way is not comparable with a
median duration of breastfeeding indicator calculated using children 0-35.9 months of age.