Breastfeeding Practices, Infant Formula Use, Complementary Feeding and Childhood Malnutrition: An Updated Overview of the Eastern Mediterranean Landscape

Background: With increasing global rates of overweight, obesity and non-communicable diseases (NCDs) along with undernutrition and micronutrient deficiencies, the Eastern Mediterranean Region (EMR) is no exception. This review focuses on specific nutrition parameters among under five years children, namely ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods and malnutrition. Methodology: PubMed, Google Scholar, United Nations International Children’s Emergency Fund (UNICEF) databases, World Health Organization (WHO) databases, the World Bank databases and the Global Nutrition Report databases were explored between 10 January and 6 June 2022, to review the nutrition situation among under five years children in the EMR. Results: The regional average prevalence of ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods was estimated at 84.3%, 30.9%, 42.9%, 41.5%, 32.1% and 69.3%, respectively. Iran, Iraq, Libya and Palestine have seen a decline over time in the prevalence of exclusive breastfeeding. Lebanon, Egypt, Kuwait and Saudi Arabia reported early introduction of infant formula. Moreover, Lebanon, Pakistan, Saudi Arabia and United Arab Emirates were seen to introduce food early to the child, at between 4–6 months of age. The estimated weighted regional averages for stunting, wasting and underweight were 20.3%, 8.9% and 13.1%, respectively. Of concern is the increasing prevalence of stunting in Libya. As for overweight and obesity, the average prevalence was reported to be 8.9% and 3%, respectively. Lebanon, Libya, Kuwait and Palestine showed an increased trend throughout this time. Conclusions: In this review, the suboptimal infant and young child feeding patterns and the twofold incidence of malnutrition in the EMR are highlighted and we urge the prioritizing of measures to improve children’s nutrition.


Type of Studies and Participants
National published data and English-language publications were included in the search. We also included cross-sectional studies, longitudinal studies, retrospective and prospective, cohort studies and reports. However, reviews and systematic reviews were excluded. Additionally, our target population was constituted of healthy children under the age of five years living in one of the EMR countries listed previously. Studies enrolling children aged above 5 years and having one or more chronic diseases (cardiovascular diseases, diabetes, cancer, chronic kidney diseases and others), were excluded from our search. This review included 326,299 children under the age of 2 for the analysis of the infant and young child feeding practices and 476,928 children under 5 years of age for the analysis of malnutrition parameters; hence, we expect a higher number of children than that reported. These numbers were derived only from the national studies included in this review; however, many other data retrieved from the United Nations International Children's Emergency Fund (UNICEF) databases, the World Health Organization (WHO) databases, the World Bank databases and the Global Nutrition Report databases did not include the number of children.

Type of Outcomes Reviewed
For infant feeding practices and malnutrition among under five years children, the following parameters proposed by WHO and UNICEF were reviewed. Breastfeeding parameters included: ever breastfed (0-23 months), exclusive breastfeeding under 6 months, mixed milk feeding under 6 months and continued breastfeeding (12-23 months). The prevalence of bottle feeding under 6 months of age was also reported. Complementary feeding parameters included: introduction of solid, semi-solid, or soft foods (6-8 months). Malnutrition parameters among children under the age of 5 years included 2 broad groups: (1) undernutrition: stunting, wasting and underweight, defined as height-for-age z score < −2 standard deviations (SD), weight-for-height z score < −2 SD, weight-for-age z score < −2 SD, respectively, (2) overnutrition: overweight and obesity, defined as weight-for-height z score >2 SD and weight-for-height z score >3 SD, respectively [14].

Data Extraction
To identify papers that were appropriate and pertinent to the review's objectives, the reviewers first scanned the titles and abstracts of the citations. The data were searched between the years 1988 and 2022. Further, for the articles that seemed to be relevant, the full text study report was obtained and the data was extracted using an Excel template, which included the following details: study number, study title, authors' name, year of publication, type of study, country, study objectives, study design and participants, study variables and tools, statistical test used and pertinent findings. The selection process is shown in Figure 1. Based on the information available, the weighted regional average for each nutrition parameter was determined. Additionally, the average annual rate of reduction (AARR) for particular nutrition parameters was estimated when data were available at different time points. The methodology for calculating the AARR can be found in the UNICEF technical report [15]. publication, type of study, country, study objectives, study design and participants, study variables and tools, statistical test used and pertinent findings. The selection process is shown in Figure 1. Based on the information available, the weighted regional average for each nutrition parameter was determined. Additionally, the average annual rate of reduction (AARR) for particular nutrition parameters was estimated when data were available at different time points. The methodology for calculating the AARR can be found in the UNICEF technical report [15].

International Overview
The global average prevalence of exclusive breastfeeding was shown to be 44% [35]. Besides, the estimated average prevalence of exclusive breastfeeding reported from the North America Region [35], the East Asia and Pacific Region [35] the Latin America and Caribbean Region [35], the South Asia Region [35] and the Europe and Central Asia Region [35] was 26%, 31%, 37%, 57% and 41%, respectively. Regarding continued breastfeeding, the estimated global average prevalence was 65% [37]. As for the East Asia and Pacific Region excluding China [37], the Latin America and Caribbean Region [37], the South Asia Region [37], the Europe and Central Asia Region [37] and the North America Region [37], the prevalence of continued breastfeeding was 58%, 45%, 78%, 50% and 12%, respectively. Globally, the estimate average prevalence of introduction of solid, semi-solid, or soft foods (69.3%) was 73% [37]. This prevalence was reported, among different regions, as follows: the East Asia and Pacific Region (84%) [37], the Latin America and Caribbean Region (87%) [37], the Europe and Central Asia Region (76%) [37], the South Asia Region (58%) [37].

Discussion
This review highlighted the feeding patterns of infant and young children in the EMR. The regional average prevalence of ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, and introduction of solid, semi-solid, or soft foods was estimated at 84.3%, 30.9%, 42.9%, 41.5%, 32.1% and 69.3%, respectively. Over time, some countries in the EMR region have seen a decline in the prevalence of exclusive breastfeeding, such as Iran, Iraq, Libya and Palestine. Further-more, Lebanon, Egypt, Kuwait and Saudi Arabia reported early introduction of infant formula. Lebanon, Pakistan, Saudi Arabia and United Arab Emirates were also seen to introduce food early to the child, between 4-6 months of age. Additionally, this paper underlined the double burden of malnutrition among under five years children in the EMR, with undernutrition coexisting with overnutrition in most countries. The estimated weighted regional averages for stunting, wasting and underweight were 20.3%, 8.9% and 13.1%, respectively. Of concern is the increasing prevalence of stunting that has been observed in Libya. As for overweight and obesity, the average prevalence was reported to be 8.9% and 0.9%, respectively. Lebanon, Libya, Kuwait and Palestine described an increased trend throughout this time.

Infant and Young Child Feeding Practices
Despite the fact that the majority of children in the EMR were breastfed at some point during their childhood, the regional average prevalence of exclusive breastfeeding during the first six months of life was only 30.9%. This rate was much lower than the global average prevalence of exclusive breastfeeding (44%) [35], lower than the estimated average prevalence reported from the Latin America and Caribbean Region (37%) [35], the South Asia Region (57%) [35] and the Europe and Central Asia Region (41%) [35], higher than that reported from the North America Region (26%) [35], similar to that of the East Asia and Pacific Region (31%) [35] and far from the WHO global goal of 50% exclusive breastfeeding by 2025 and 70% by 2030 [126]. The reported de-cline in exclusive breastfeeding in certain countries of the region is of greater concern. Furthermore, decreased rates of continued breastfeeding, particularly throughout the child's second year, and increased proportion of bottle feeding and mixed milk feeding were described in the EMR. The prevalence of bottle feeding is highest in Western Europe, Australia and North America regions, but these countries' rates are stable, while the Middle East and North Africa regions are expected to have the biggest increases [127,128]. The estimated regional average of continued breastfeeding (41.5%) was considerably lower than the global average (65%) [37], the East Asia and Pacific Region excluding China (58%) [37], the Latin America and Caribbean Region (45%) [37], the South Asia Region (78%) [37] and the Europe and Central Asia Region (50%) [37]. However, our findings were higher than the North America Region (12%) [37]. This inadequate adherence to the WHO infant feeding guidelines could have an adverse impact on the disease burden in the EMR. Referring to the literature, it has been demonstrated that healthy and optimal nutrition at earlier stages in the infants' life may have a critical role in promoting cognitive and physical growth, boosting immunity, reducing the risk of childhood obesity and preventing NCDs [4,129,130]. Poor Baby-friendly Hospital Initiative (BFHI) and Code implementation, the limited knowledge of healthcare professionals in assisting breastfeeding mothers, high rates of pre-lacteal feeding, the absence of designated maternity facilities such as lactation rooms in workplaces and inadequate support for breastfeeding mothers may be accountable for the inadequate status of the aforementioned breastfeeding parameters [131][132][133][134][135]. When it comes to complementary feeding, the majority of EMR infants were introduced to solid, semi-solid, or soft meals at 6-8 months; this was in accordance with the WHO recommendations [126]. Yet our estimate average prevalence of introduction of solid, semi-solid, or soft foods (69.3%) was lower than the global estimated average (73%) [37], the East Asia and Pacific Region (84%) [37], the Latin America and Caribbean Region (87%) [37] and the Europe and Central Asia Region (76%) [37] and higher than the South Asia Region (58%) [37]. However, some EMR countries (Lebanon, Pakistan, Saudi Arabia and United Arab Emirates) were seen to introduce food early to the child. Early introduction of solid, semi-solid, or soft foods has been shown to lower consumption of protective components contained in breastmilk, which may increase newborn morbidity. After introducing solid food, women might consequently produce less breastmilk, which could negatively impact the infant's intake of nutrients. Additionally, improper handling and storage of complementary foods might expose infants to dangerous microbes [4,136]. Besides, low socioeconomic status, food insecurity and traditions are all significant factors that have an impact on complementary feeding practices [137][138][139][140]. Although some countries of the region showed some progress, all in all a decreasing trend was recorded in the infant and young child feeding parameters; hence, further interventions are needed.

Malnutrition Status among Under-5 Years Children
The results of this research demonstrated that undernutrition among young children continues to be a major problem in a number of countries in the region. According to the WHO cutoffs, only a few countries (Jordan, Kuwait, Morocco, Qatar and Tunisia) had levels of wasting below the recommended threshold of 3% [11], while the regional average (8.9%) was higher. The regional average was also observed to be higher than the worldwide average of wasting (6.7%) [92], as well as estimates from East Asia and the Pacific (3.7%) [92], Latin America and the Caribbean (1.3%) [92] and North America (0.2%) [92], although it was lower than those reported from South Asia (14.7%) [92]. As for underweight, the regional average (13.1%) was lower than that reported in 2018 (18%) [3], indicating that there has been some progress on this front. This regional average was close to the global average (12.6%) [99], higher than that of East Asia and Pacific (5.2%) [99], Latin America and Caribbean (2.7%) [99] and North America (0.7%) [99], while it was lower than that reported from South Asia (27.4%) [99]. Additionally, a rise in the prevalence of stunting was noted in Libya, underlining the country's growing vulnerability to chronic undernutrition. Stunting prevalence in the region was assessed to have an AARR of 2.5%, which was lower than the rate required to meet the global nutrition target set by the World Health Assembly (AARR = 3.9%) [141]. Actually, Lebanon (AARR = 4.5%), Afghanistan (AARR = 4.1%), Iraq (AARR = 10.4%), Morocco (AARR = 4.5%), Palestine (AARR = 7.2%) and Saudi Arabia (AARR = 5.9%) seemed to be making some progress toward achieving the target. The regional average of stunting (20.3%) exceeded estimates reported from East Asia and Pacific (13.4%) [104], Latin America and Caribbean (11.3%) [104], North America (3.2%) [104], Central Europe and the Baltics (4.5%) [104], and Europe and Central Asia (5.7%) [104], although it was lower than that of South Asia (31.8%) [104] and close to the worldwide average of 22% [104]. Stunting, wasting and underweight rates have been declining in some countries of the region and this trend may be attributed to a number of factors, including higher levels of maternal education, a gradual rise in the number of women's and children's health centers, a higher percentage of women receiving antenatal care, and increased vaccination rates [142,143]. However, conflicts, economic and political instability and the COVID-19 pandemic together led to no progress and even an increase in this trend, in other countries of the EMR [3,4].
Overweight and obesity in under five years children in the region are of utmost concern. Among pre-school aged children, the prevalence of overweight/obesity increased in several countries, including Lebanon, Libya, Kuwait and Palestine. The estimated regional average for overweight among under five years children was 8.9%, which exceeds the worldwide average (5.7%) [106] and that reported for East Asia and Pacific (7.8%) [106], Latin America and Caribbean (7.5%) [106], North America (9.1%) [106], Central Europe and the Baltics (6.6%) [106] and Europe and Central Asia (7.9%) [106], but it was lower than estimates reported for South Asia (2.2%) [106]. As for obesity, the average regional estimate (3%) was lower than the average prevalence reported in Latin America and Caribbean (9.2%) [125] and Central and Eastern Europe and Central Asia (10.9%) [125]. Juvenile obesity can cause adverse health effects later on in children's life [144][145][146]. Higher and lower socioeconomic status, parental obesity, sedentary lifestyle, high intake of sugar and fat rich food and low adherence to a balanced and healthy diet have been identified as risk factors for childhood obesity [147][148][149][150]. In order to promote better diets as part of effective obesity prevention and nutrition policies, the focus should be on unhealthy diets and feeding patterns and, more specifically, on the requirement to restrict the marketing of food and beverages to children [151].

Strength and Limitations
Our review provides updated data on the nutritional situation among under five years children in the EMR; it sheds important light on infant and young child feeding parameters including ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods, as well as malnutrition parameters including undernutrition: wasting, stunting, under-weight and overnutrition: overweight, obesity. However, this study has some limitations. In many cases, the lack of recent, nationally representative research assessing the nutritional status of the pre-school children population in several countries in the region and the lack of studies examining long-term trends in nutritional parameters limited the data on nutritional parameters that were available.

Conclusions
Inadequate infant feeding practices is one of the leading factors contributing to the increased rates of malnutrition in all of its various form. In light of this, the thorough search conducted in this study urges prompt action to address the suboptimal feeding patterns and the double burden of malnutrition among under five years children in the EMR. Therefore, the improvement of the population's nutritional status should be a top priority, especially for infants and young children.