Association of feeding practices with growth in infants: a longitudinal observational study in a rural district of Pakistan.

Exclusive breastfeeding (EBF) is recommended for the first 6 months of an infant's life, but barriers to EBF persist due to sociocultural, economic and health-related factors in resource-poor settings. This study examines the association between feeding practices and malnutrition in a birth cohort from a rural district of Pakistan. Data were collected from a cohort of n=2697 infants, up to 6 months of age, through routine household visits by community health workers. The study analysed demographic characteristics, feeding practices, anthropometric and health information of infants and their mothers. Breastfeeding practices varied, with EBF being more common in the first month, while predominant breastfeeding (breastmilk with non-milk liquids) was most prevalent from 1 to 6 months. Almost all (98.3%) infants had been breastfed at some point between birth and 6 months but <10% were being exclusively breastfed by 6 months of age, with a significant proportion already identified as wasting (14.7%), stunted (36.7%) and underweight (38.5%) at baseline (birth). Early initiation of complementary feeding or breastmilk alternatives before 4 months was significantly associated with increased odds of wasting by 6 months of age (adjusted OR (AOR)=4.14; 95% CI: 1.95 to 8.77; p<0.001). Infants not born in medical facilities had higher risks of wasting (AOR=2.43; 95% CI: 1.13 to 5.21) and underweight status (AOR=1.74; 95% CI: 1.13 to 2.71). Our study indicates that infants were over four times more likely to be malnourished by 6 months if complementary feeding was initiated before 4 months of age. While causal relations/directionality cannot be established from these findings, we believe that parents may resort to suboptimal complementary feeding practices shortly after birth, due to perceived inadequate infant growth. A tailored approach addressing systemic barriers to optimal feeding practices is recommended for resource-constrained, nutrition-poor settings, such as rural Pakistan.