Original Article

Effect of Feeding Practices on Nutritional Status of Infant

and Young Children Residing in Urban Slums of Berhampur:
A Decision Tree Approach
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Durga Madhab Satapathy1, Nivedita Karmee2, Sanjaya Kumar Sahoo3, Sithun Kumar Patro4, Debasish Pandit4
1
Professor and HOD, Associate Professor, 3Assistant Professor, 4Senior Resident, Department of Community Medicine, MKCG Medical College, Berhampur, Odisha,
2
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India

Abstract
Background: Appropriate infant and young child feeding (IYCF) practices in the early years of life will ensure optimal growth and development
of the child. However, many children are not fed in the recommended way. Objectives: To assess the risk of malnutrition as a result of
various feeding practice patterns among the children with the application of the decision tree algorithm. Methods: It was a community‑based
cross‑sectional study conducted in the urban slums of Berhampur Municipal Corporation in Ganjam District, Odisha, India, from January to
December 2019. Among a sample of 360 children of 6–23 months, nutritional status and feeding practices were determined. Data were analyzed
using R version 3.6.1 developed by R Foundation for Statistical Computing, Vienna, Austria. The effect of IYCF practices on nutritional status
was explained with the decision tree method with the use of a Chi‑squared automatic interaction detection algorithm. Results: The prevalence
of children with early initiation of breastfeeding (EIBF), exclusive breastfeeding (EBF), minimum meal frequency (MMF), and minimum
dietary diversity (MDD) was 62.2%, 59.7%, 41.9%, and 19.4%, respectively. The prevalence of wasting, stunting, and underweight among
the participants was 36.4%, 31.1%, and 35.3%, respectively. The significant factors which classified and predicted wasting were EBF, EIBF,
and MDD, for stunting factors were EBF, MMF, and MDD and for underweight, significant factors were EBF, EIBF, and MDD. Conclusion:
With the decision tree approach, the probability of malnutrition in relation to various feeding practices patterns can be easily explained to the
mothers and health workers as compared to interpreting odds ratio and strict adherence to IYCF guidelines can also be ensured.

Key words: Decision tree, infants, infant and young child feeding, malnutrition, slums, young children

Introduction child. Optimal IYCF practice helps prevent the development

The first 2 years of life are the “critical window of opportunity.”[1]
The adaptation of correct infant and young child feeding (IYCF)
practices from the beginning will ensure children’s optimal
growth and development.[2] However, many children are not fed
in the proper way. Although breastfeeding is now universally
practiced, many mothers start breastfeeding lately or who
initiate the breastfeeding satisfactory, often start complementary
feeding early or breastfeeding stopped within a few weeks of
life.[3] Many children have sub‑optimal complementary feeding
in terms of meal frequency and dietary diversity.
of chronic diseases in adulthood.
The snapshot of IYCF practices in urban India is not promising.
Only two-thirds of the children (67.6%) were breastfed within
1 h of birth, 64.3% of children were exclusively breastfed,
and regarding complementary feeding only 9.4% of children
Address for correspondence: Dr. Debasish Pandit,
Department of Community Medicine, MKCG Medical College, Berhampur,
Odisha, India.
E‑mail: dpandit07@gmail.com

Annually 45% of child deaths are due to undernutrition.

This is an open access journal, and articles are distributed under the terms of the Creative
Adequate nutrition during early childhood, especially in the Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
first 2 years of life, results in a reduction in morbidity and remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
mortality.[4] It is also related to the cognitive development of the is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Access this article online
Quick Response Code:
Website: Submitted: 17‑Dec‑2020 Revised: 18‑Feb‑2021
www.ijph.in Accepted: 04‑May‑2021 Published: 14-Jun-2021

How to cite this article: Satapathy DM, Karmee N, Sahoo SK, Patro SK,
DOI: Pandit D. Effect of feeding practices on nutritional status of infant and young
10.4103/ijph.IJPH_1272_20 children residing in urban slums of berhampur: A decision tree approach.
Indian J Public Health 2021;65:147-51.

© 2021 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow 147
 Satapathy, et al.: Effect of IYCF practices on nutritional status: A decision tree approach
receiving adequate diet.[5] Similarly for under‑five nutritional
status, more than one‑third of the world’s malnutritional
children live in India. The prevalence of wasting, stunting,
and underweight in urban areas is 27.2%, 17.0%, and 26.2%,
respectively.[5]
At present, the Indian population is experiencing a triple state
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of transition, i.e., demographic, economic, and epidemiological
transition. The transition phases resulted in rapid urbanization
which gave rise to the establishment of slums. The poor
living conditions imposed a great risk of malnutrition among
children.[6] Besides, poor feeding practices among infants and
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young children enhance the risk of malnutrition further.
Therefore, to address the problem, the present study was
conducted to assess the risk of malnutrition as a result of
various feeding practice patterns among the children residing in
urban slums. The decision tree method was applied to classify
the participants based on their feeding practices and weigh the
risk of malnutrition among various sub‑groups.
Materials and Methods
This was a community‑based, cross‑sectional study conducted in
the urban slums of Berhampur Municipal Corporation (BeMC)
which is located in Ganjam District, Odisha. BeMC has
174 notified slum areas distributed in 37 wards. [7] The
study was carried out for a period of 1 year from January
to December 2019. The study participants were the children
age 6–23 months residing in the urban slums for 1 year. The
sample size was determined using the following formula
Z2 PQ/l2, where, Z = 1.96 (Z value for 95% level of significance),
P = 64.3% (Prevalence of exclusively breastfeeding in
Odisha as per NFHS‑4 survey[5]), Q = 35.7% (100‑P), and
l = 5% (Absolute precession) and it was found to be 353.Finally
a total of 360 participants were selected for this study.
The average number of children of aged 6–23 months residing
in each slum was found to be 14 + 3.7. Hence, considering
availability of 10 children of aged 6–23 months in each slum
area, the participants were selected by two‑stage simple
random sampling. First, out of 174 notified slums areas, 36
slums were randomly selected and from each, 10 participants
were selected randomly. Children whose parents were not
willing to participate in the study and children with a congenital
malformation, mental retardation, and critically ill were
excluded from the study.
Sociodemographic characteristics and infant feeding practices
were recorded using a predesigned and pretested modified
IYCF questionnaire by 24 h of dietary recall method.[8] The
nutritional status of the children was assessed by calculating
Z‑scores for height for age, weight for age, and weight for
height and comparing with WHO Child Growth Standards.[9]
The feeding practices of the infant and young child were
assessed with the help of IYCF core indicators.[10] Data were
tabulated in Microsoft excel 2016 and analyzed using R version
3.6.1, R Foundation for Statistical Computing, Vienna, Austria
148
QGIS version 2.18, OSGeo Foundation, Chicago, USA. The
quantitative variable was expressed in mean and standard
deviation (SD), and the qualitative variables were expressed
in proportion and frequency. The effect of IYCF practices on
nutritional status was explained with the decision tree method.
The algorithm used was Chi‑squared automatic interaction
detection (CHAID).[11] CHAID is a statistical method to create
homogeneous groups based on the value of a specific outcome
variable (wasting, stunting, and underweight) by splitting cases
into two or more groups on the basis of designated predictor
variables (Feeding practices). After each split, the resulting
groups are evaluated separately to see if a further split on
any of the predictor variables would create significantly more
homogenous groups. When it is no longer possible to make
the resulting groups more homogenous (at a significance level
of a = 0.05), the program halts. These final groups are called
“terminal nodes,” and represent the most homogenous groups
that can be created given the predictor variables and specified a
level.[12] CHAID is a particularly useful technique when a study
is exploratory rather than confirmatory in nature, involves the
relationships between a number of independent variables and
a single dependent variable, when the independent variables
interact with each other, and when there is no strong theory
concerning the relative importance of the independent
variables in predicting the dependent variable.[13] The CHAID
analysis was run in duplicate with parent nodes defined as
20 participants, child node defined as 5 participants, and
significance set at (αmerge, αsplit, and P < 0.05).
Ethical issues
Ethics clearance was obtained from the Institutional Ethical
Committee of M.K.C.G. Medical College and Hospital to
conduct the study. The data collection was conducted only
after obtaining written consent from the parents of the study
participants.
Results
A total of 360 children were included in the study; among
them 52.5% were male and 47.5% were female. The mean
age of males was 13.2 ± 4.68 months and for females, it
was 12.83 ± 4.51 months. The number of participants aged
16–23 months was 30.8% followed by 12–15 months (30.3%).
About 62.2% of the mothers had initiated breastfeeding
within 1 h of birth i.e. early initiation of breastfeeding (EIBF).
Similarly, 59.7% had practiced exclusive breastfeeding (EBF)
for 6 months. Regarding complementary feeding, among
the infants, 51.1% had received complementary food at the
age of 6–8 months i.e. timely initiation of complementary
feeding, 41.9% of the babies were taking minimum prescribed
frequency of meal as per IYCF guideline minimum meal
frequency (MMF), 46 and the dietary diversity of 4 or more
food groups in their meals was found among 19.4% i.e.
minimum dietary diversity (MDD). However, the practice
of minimum acceptable diet was seen in only 9.7% of the
participants [Table 1].
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 Satapathy, et al.: Effect of IYCF practices on nutritional status: A decision tree approach
Table 1: Prevalence of various feeding practices and
malnutrition among the study participants (n=360)
Parameters Frequency, n (%)
Feeding practices
EIBF 224 (62.2)
EBF 215 (59.7)
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TICF 184 (51.1)
MMF 151 (41.9)
MDD 70 (19.4)
MAD 35 (9.7)
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Nutritional status
Wasting (WFH<−2 SD) 131 (36.4)
Stunting (HFA<−2 SD) 112 (31.1)
Under‑weight (WFA<−2 SD) 127 (35.3)
EIBF: Early initiation of breastfeeding, EBF: Exclusive breastfeeding,
TICF: Timely initiation of complentary feeding, MMF: Minimum meal
frequency, MDD: Minimum dietary diversity, MAD: Minimum acceptable
diet, HFA: Height for age, WFA: Weight for age, WFH: Weight for height,
SD: Standard deviation
In the present study, 31.1% of the children were found to have
Z‑score of height <‒2 SD for their age (Stunting), 35.3% had
a Z‑score of weight <‒2 SD for their age (Underweight), and
36.4% children had a Z‑score of weight <‒2 SD for their
height (Wasting) [Table 1].
Decision tree evaluation
The decision tree algorithm was used to statistically classify
the participants into various subgroups based on their feeding
practices (EIBF, EBF, MMF, MDD, and TIBF) and predict
the risk of occurrence of stunting, wasting, and underweight
among the subgroups formed.
EBF is the most powerful factor (Chi‑square = 45.60,
P < 0.001) for classifying participants into subgroups and
predicting wasting [Figure 1]. The probability of occurrence of
wasting was maximum among non‑EBF subgroups (i.e., 0.54),
and those subgroups who were exclusively breastfed, EIBF
further subgrouped and determined (Chi‑square = 17.09,
P < 0.001) the probability of wasting. The probability of
wasting among EBF children but delayed initiation of
breastfeeding was found to be 0.41. The subgroups with
children having EIBF and EBF, MDD (Chi‑square = 5.23,
P < 0.02) is the classifying and determining factor to assess the
probability of the wasting. The probability of wasting was the
lowest in the subgroups with EBF, EIBF, and MDD (i.e. 0.04)
as compared to those who did not have MDD in their meals.
(i.e., 0.19).
EBF is the most powerful factor (Chi‑square = 11.64,
P = 0.001) for classifying the participants into primary
subgroups and for predicting stunting [Figure 2]. In the
subgroup of children with non‑EBF, MMF (Chi‑square = 7.98,
P = 0.005) helps in further classifying and determining the
probability of stunting. The probability of stunting among
non‑EBF and non‑MMF was 0.53 and MMF was 0.29.
However, in subgroups of children with EBF, MDD helps
in classifying further and determining (Chi‑square = 4.72,
Indian Journal of Public Health ¦ Volume 65 ¦ Issue 2 ¦ April-June 2021
P = 0.03), the probability of stunting. The probability of
stunting among those with EBF and without MDD was 0.29
and those with MDD were 0.14.
EBF is the most powerful factor (Chi‑square = 33, P < 0.001)
for the classification of participants based on their feeding
practices and prediction of underweight [Figure 2]. Further, in
the subgroup with children who were nonexclusively breastfed,
EIBF (Chi‑square = 5.7, P = 0.017) determined the probability
of underweight, and those with EBF, MDD and EIBF classified
and determined the probability of underweight. The probability
of underweight is the highest among children with non‑EBF
and delayed initiation of breastfeeding (i.e., 0.62) and is lowest
among children having EBF, EIBF, and MDD (i.e., 0.1).
The timely initiation of complementary feeding indicator was
not found significant while classifying the sample population
and prediction of probability for wasting, stunting, and
under‑weight.
Discussion
Malnutrition in the first 2 years which is a crucial period of
life can be prevented by early and EBF followed by adequate,
safe, and age‑appropriate complementary feeding.
Regarding IYCF practices, 62.2% of children were breastfed
within 1 h of birth (EIBF) and 59.7% were exclusively
breastfed up to 6 months (EBF). This finding was slightly
lower as compared to the NFHS‑4 survey for Odisha where
the proportion of EIBF and EBF for the urban population was
67.6% and 64.3%, respectively.[5] However, EIBF practices
among our study participants were much higher than the
study conducted by Davara et al. and Bhushan in a similar set
up where the proportion of EIBF was 45%[14] and 39.6%,[15]
respectively.
The finding from the study conducted by Mog and Datta
showed the proportion of EBF in the urban slums of the
Tripura district was similar to our study, i.e., 60.5%.[16]
However, a study conducted by Panigrahi and Sharma and
Chakraborty et al. showed the EBF among the slum areas of
Bhubaneswar and Durgapur was lower as compared to our
study, i.e., 21.2%[17] and 27.6%,[18] respectively.
In this study, the proportion of children who had MMF as per
their age was found to be 41.9% and the proportion having dietary
diversity in their meal was found to be 19.4%. Similar findings
were observed in the study conducted by Tegegne et al. where
the MMF among the study participants was found to be 49.6%;[19]
however, the study conducted by Chaudhary et al. in the urban
slums of Ahmadabad, the MMF was found to be 64.3%.[20]
The nutritional status of the children was assessed and it was
found that the proportion of stunting, wasting, and underweight
in the urban slums of Berhampur were 31.1%, 36.4%, and
35.3%, respectively. The proportion of malnutrition in our
study was higher as compared to the NFHS‑Odisha survey
where the proportion of stunted, wasted, and underweight
149
 Satapathy, et al.: Effect of IYCF practices on nutritional status: A decision tree approach
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Figure 1: Decision Tree: Probability of Stunting among the study
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par ticipants wr t to their feeding practices, MMF: Minimum Meal
Frequency, EBF: Exclusive breastfeeding, MDD: Minimum dietary diversity.
Figure 2: Decision Tree: Prediction of Underweight among the study
participants wrt to their feeding practices, EIBF: Early initiation of
breastfeeding, EBF: Exclusive breastfeeding, MDD: Minimum dietary
diversity.
Figure 3: Decision Tree: Probability of wasting among the study
participants wrt to their feeding practices, EIBF: Early initiation of
breastfeeding, EBF: Exclusive breastfeeding, MDD: Minimum dietary
diversity.
children in the urban areas was 27.2%, 17.0%, and 26.3%
respectively.[5] However, a study conducted by Houghton
et al. in the urban slums of Delhi found that among the
children residing in slums areas, 39% were stunted, 31%
underweight, and 10% wasted[21] and another study conducted
by Lohia and Udipi in the urban slums of Mumbai found that
among participants, nearly 51.3% were stunted, 26.7were
underweight, and 41.7% were wasted.[22]
150
Proper child feeding practices, especially breastfeeding and
complementary feeding are two important interventions that
can reduce acute malnutrition along with stunting in the early
years of childhood. In our study “decision tree” approach,
a classification‑based model was used to subgroup the
participants based on their feeding practices and predict the
probability of undernutrition such as wasting, stunting, and
under‑weight among the sub‑groups formed. The benefit of
using this model is that the tree formed is easy to interpret and
make others understand the impacts of feeding practices on the
nutritional status of children at the village level.
EBF, EIBF, and MDD were the significant factors that
classified the study participants statistically (P < 0.05) and
predicted the probability of wasting in the Figure 3 of the
present study. A study conducted by Bentley et al. also showed
the odds of wasting were lower among those with EIBF and
MMF and MDD in their meals.[23] Another study conducted
by Chaudhary et al. found the significant negative association
between wasting and EBF, EIBF, and MMF but no association
with MDD.[20] Sheikh et al. in their study found that the odds
of having wasting were 0.22 times less likely for a child who
received MDD and MMF, respectively.[24] In our study, EBF
was the principal factor that determined the probability of
wasting among our study participants. The probability of
wasting among the non‑EBF children was found to be 0.54,
whereas the subgroups with EBF but non‑MDD the probability
was 0.41, and subgroups with EBF and MDD the probability
was minimal, i.e., 0.19. This indicates the better the nutritional
practices as per WHO IYCF guideline, the lesser will be the
risk of wasting among the children.
Similarly, EBF, MMF, and MDD were the significant
factors (P < 0.05) which classified the participants into two
subgroups and predicted the probability of stunting among
them. EBF was the primary node to determine the stunting
and subsequent nodes were MMF and MDD in different
groups. The probability of stunting was the highest among the
subgroups with non‑EBF and non‑MMF (0.53) and lowest for
the children who were EBF and had MMD in their diets. The
study conducted by Uwiringiyimana et al. found the significant
negative association of stunting with EBF.[25] Similarly,
the study conducted by Appiah et al. reported a significant
relationship between stunting and MMF among the children
aged 6‒23 months.[26]
For underweight, EBF, EIBF, and MDD were the significant
factors (P < 0.05) which classified and predicted the
probability of underweight among the study participants.
A study conducted by Hashmi et al. reported that there was
a significant association between underweight and MMF in
their study participants.[27] In our study, EBF was the principal
node that classified the participants into two sub‑groups. The
sub‑group with non‑EBF, EIBF was the determinant factor
whereas the sub‑group with EBF, both EIBF and MDD were
the determinant factors for underweight. The probability of
underweight was the highest among those having delayed
Indian Journal of Public Health ¦ Volume 65 ¦ Issue 2 ¦ April-June 2021
 Satapathy, et al.: Effect of IYCF practices on nutritional status: A decision tree approach
initiation of breastfeeding and nonexclusively breastfed
children (0.62) and lowest for the sub‑group having EIBF,
EBF, and MDD practices (0.1).
Conclusion
With the decision tree approach, the outcome and probability
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of malnutrition concerning the subgroups formed by various
feeding practices can be easily explained. This method of
presentation will help the mothers to understand the pattern
of IYCF practices and the possibility of malnutrition in their
baby as compared to interpreting the odds ratio. The risk
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of malnutrition among the children of urban slums can be
addressed by strict adherence to the IYCF guidelines and
continuous monitoring of the feeding practices by health
workers.
Acknowledgments
The author would like to acknowledge the study participants
who spend their valuable times and for full cooperation. The
author would also like to acknowledge the ASHAs, USHAs,
and ANMs of BeMC who coordinate the participants during
the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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