Like many developing countries, stunting and wasting have long been major nutritional problems in Nepal. The existing high proportion of under nutrition (41% stunting and 13% underweight among under five children) makes it complicated to reduce the under-five mortality in Nepal . Nepal is a signatory of the millennium development goals (MDG)  and has achieved a significant reduction in child mortality . It has committed to reduce child mortality by a further two-thirds by 2015 from the 1990 figures. Nepal has also committed to reduce extreme poverty and hunger . Both of these goals are closely related to under nutrition and progress towards reaching these goals will be limited if the under nutrition is not reduced substantially. Not limited to these two goals, all other MDGs are directly or indirectly related to nutrition and are likely to worsen by under nutrition . To reduce under nutrition adequate, safe and acceptable child feeding is essential. For this reason, WHO and UNICEF have recommended eight core infant feeding practices to be adopted . To better promote such recommended practices, it is essential to demonstrate the evidence on the existing proportion of children reaching the dietary practice’s goals. This study reports the proportion and the determinants of receiving the recommended diets among the 6–23 months Nepalese children.
Three infant and young child feeding practices (minimum dietary diversity, minimum meal frequency and minimum acceptable diet) were assessed in this study based on the WHO recommendation and indicators [7, 9, 15]. It was found that only 30.4% of children received the recommended minimum dietary diversity, 26.5% received an acceptable diet and 76.6% received the recommended minimum meal frequency.The proportion of breastfed children provided with minimum acceptable diet was 27.4% which was slightly lower than the figure in 2006 (32%) . In 2006 , 34% and 82% of the breastfed children received the minimum diversity and minimum meal frequency, respectively.
The prevalence of meeting these infant feeding practices varies across the countries in South Asia. The minimum diversity criteria reported in this study was higher than India (15.2%) but lower than Bangladesh (41.9%) and Sri Lanka (71.1%) . Likewise, meal frequency was also less than in Bangladesh (81.1%) and Sri Lanka (88.3%). Current findings for attaining the minimum acceptable diet for children were also lower than previous studies in Nepal, Sri Lanka and Bangladesh . It is difficult to determine how high the population percentage for infant and young child feeding practices would need to be in order to significantly eliminate current levels of under nutrition among children in Nepal. The WHO guidelines on infant feeding do not provide the baseline or the minimum standard that needs to be reached nor what percentage should be considered alarming for public health significance [7, 15]. Logically, it is desirable that all young children (6–23 months) meet the recommended feeding practices.
To understand the low levels of dietary diversity and acceptable diet provided to Nepalese children, it is necessary to look at the food items provided to children. The majority of food items given to Nepalese children were from the grains, roots or tubers (Food Group 1) that are rich in carbohydrate (energy). Food items from the other six food groups were given to less than a half of the children. When diversity does not exist across the food items, it negatively affects the findings for minimum dietary diversity and acceptable diet.
A notable finding was a major change in diets across the various age groups that improved with age. This finding suggested that the youngest age group 6–11 months received the lowest proportion of food from all seven categories of food. This age group was least likely to meet the recommended meal frequency, meal diversity and acceptable diet standard than the older (12–23) children. It shows that 6–11 months children were even more at risk of under nutrition and micronutrient deficiency. The children of age group 6–23 months go through a reasonably rapid dietary transition from exclusive breastfeeding to complementary feeding. While changing the diet, they are vulnerable to diarrhoeal infections [20, 21]. During this period, young children need more nutrition to overcome the adverse effect of such illness. Unfortunately, the current finding indicated that the children in this age group were not getting complementary foods as recommended by the WHO.
Nepal has achieved significant progress in reducing vitamin A deficiency disorders such as night blindness . This achievement was mainly due to the high dose vitamin A supplementations that are provided twice a year to all under-five children. This supplementation is important given that currently only a third of the children in Nepal received vitamin A rich foods in their diet. A major public health strategy to increase vitamin A in the diet is to focus on dietary modification and increase consumption of vitamin A rich foods. Adequate vitamin A can be achieved through local foods but it requires careful attention to reach the need based on existing practices [22, 23]. Miller et al.  quantified the dietary modification required if a child were to depend entirely on normal diet for vitamin A without any supplementation. They reported that a child in a developing country would need to increase the proportion of vegetable and fruit by about 10 folds to attain minimally adequate liver vitamin A storage. This 10-fold increase in vitamin A rich food may not be feasible to reach in Nepal in the short term. Therefore, the existing twice a year supplementation of high dose vitamin A (2,00,000 IU) should be maintained to prevent the reversal of progress made in controlling the vitamin A deficiency disorders so far [16, 23, 24].
Factors found to be associated with one of the three infant feeding practices were attending antenatal care visits, age of mothers, development region, and ecological region, education of mothers and education of fathers.
Antenatal visits during pregnancy are not very common in Nepal. Less than a half of all pregnant mothers meet the recommended four or more ANC visits [4, 16]. Mothers who have attended at least four ANC visits may be more informed, have greater access to services and may be from a well off family, and thus more likely to be able to afford and provide a variety of foods to their children more frequently. This could explain why ANC was a significant determinant in meeting the recommended acceptable diet and meal frequency criteria.
The age of mothers at pregnancy was another determinant for dietary diversity and acceptable diet. Mothers who were pregnant at an older age (>=35 years) were more likely to provide diversity food and minimum acceptable diet than those mothers who were pregnant at the age of under 20 years. This could be due to the fact that older mothers may be more experienced/confident in feeding children and encouraging different types of foods than younger mothers .
Geographic differences are important in terms of determining the access to food and other services. The children from the Mid-western region were less likely to meet the minimum diversity and frequency criteria when compared to the children from Eastern region. Similarly, children from the Far -western region were less likely to get minimum frequency compared to the children from the Eastern region. While current results confirm the international findings for regional difference [11, 13, 14], it also reiterates an issue of insufficient child feeding in the Far-western and Mid-western part of Nepal. This could be a function of remoteness, geographic difficulties, less food production and higher levels of poverty in these regions . Children as a general rule suffer greater disadvantage when living in impoverish conditions. Mid-western and Far-western regions have been suffering from the food insufficiency for a long time especially in the hilly and the mountainous areas [26, 27]. Poverty is very high in the Mid-western and Far-western Hilly regions of Nepal. Deraniyagala  reported that the poverty levels in the Far-western and Mid-western hills were as high as three times than in the Eastern regions. Most of the Far-western and Mid-western regions have to depend on the limited amount of food provided by the government subsidies through the Nepal Food Corporation and international donors such as the World Food Program [26, 27, 29]. Unfortunately, such food aid (especially rice) has discouraged local food production such as potato, maize, barley and beans making these areas even more vulnerable for food insecurity than before. Historically there is a tension between the continuous push of imported rice and the option of encouraging locally cultivable food items such as potato, millet and barley . This tension although not directly related to the health sector, it affects the food availability in the regions and cannot be ignored as a contributing factor to child under nutrition. Our finding further re-iterated the vulnerability of the children in the Mid-western and the Far-western development regions. This finding also suggests that policy makers and program managers of health and development assistance programs need to consider the regional differences when planning for further programs aimed at improving child nutrition in order to meet the MDG.
The education level of mothers and fathers has been consistently reported as the determinant of infant feeding [14, 30]. This study also found similar results. A recent comparison of five Asian countries on infant feeding reported that mother’s education was a significant determinant of appropriate infant feeding . Sri Lanka had the highest proportion of children meeting the infant feeding guidelines for diversity, frequency and acceptability; and this was linked to the higher education status of mothers and overall literacy . The similar positive impact of education on feeding practices was also reported in a previous Nepalese study . Educated mothers and fathers are more likely to understand the education message, more likely to be engaged in the paid work and may have a higher socioeconomic level which could positively impact on infant feeding practices.
There are a number of strengths of this study. This study is based on the NDHS which used internationally validated questionnaires and methodology . The NDHS 2011 is nationally representative survey with a high response rate (>94%); therefore, the three infant feeding indicators reported in this study are generalisable for the entire country . The current findings give an indication for future interventions and a benchmark for future comparisons. It should be noted that minimum acceptable diet was closely related to the minimum dietary diversity that was similar to the findings from other South Asian countries . In future studies, dietary diversity could be considered as a simple proxy indicator for acceptable diet [12, 32].
Like any other observational studies, this study has some limitations. The cross sectional nature of the study prevents it from developing causal inference. The information in DHS surveys is based on interviews and retrospective information. There is possibility that some of the responses might suffer from recall bias and socially desirable response. This study does not take account the multistage sampling during statistical analysis. This may cause less precise estimation of standard errors and confidence interval. Another limitation related to the three infant feeding practices included in this study is the quality and amount of food given. Although the definition of the indicators deals with the variety and frequency of food, it does not take account of the quality and amount of food provided. For instance, a child who has been provided all three recommended infant feedings criteria might still not have a nutritionally adequate diet. However, for the countries whose data rely on the DHS surveys, this is the best possible evidence on the infant feeding practices at this time [1, 7].
Implication for health programs to increase recommended infant feeding
Education has been an important facilitating factor for child nutrition and development worldwide. This finding of this study that mothers with education were providing the recommended infant feeds has important public health implication. While providing formal education is beyond the roles of health workers, it is feasible for health workers to educate mothers by counselling, and to provide skills to adopt the recommended infant feeding practices. Such educational interventions are also possible in Nepal through existing mothers group meetings, female community health volunteers, and outreach clinics including primary health care outreach clinics [33, 34]. Vitamin A rich foods were provided to as few as one third of the children. This re-iterates the importance for the continuation of twice-a-year vitamin A supplementation in Nepal. Children from the Far and Mid-western development region were at most risk of not getting the recommended diets; and were at risk of suffering under nutrition. An appropriate mix of education and food supplements based on local resources could be a feasible option to increase recommended infant feeding practices and reduce under nutrition [5, 35]. However, program managers should be careful that food supplementation does not create dependency, and most importantly, does not displace the local food production system . The current findings showed that all children in the 6–23 month group were at the risk of not meeting the recommended feeding goals but it was the younger age group; the 6–11 months, who were the most vulnerable. Therefore, mothers with 6–11 month old children should be given special attention in designing education programs that promote the recommended child feeding practices while implementing additional nutritional support programs . This study suggests that there is a need for future intervention studies directed at improving the infant feeding practices in Nepal to aid in reaching the MDG and to reduce extreme poverty and hunger. Intervention studies would provide a greater insight and suggest the most appropriate intervention that works in increasing the proportion of children meeting the WHO recommended feeding practices.