Feeding practices for infants and young children during and after common illness. Evidence from South Asia

Abstract Global evidence shows that children's growth deteriorates rapidly during/after illness if foods and feeding practices do not meet the additional nutrient requirements associated with illness/convalescence. To inform policies and programmes, we conducted a review of the literature published from 1990 to 2014 to document how children 0–23 months old are fed during/after common childhood illnesses. The review indicates that infant and young child feeding (IYCF) during common childhood illnesses is far from optimal. When sick, most children continue to be breastfed, but few are breastfed more frequently, as recommended. Restriction/withdrawal of complementary foods during illness is frequent because of children's anorexia (perceived/real), poor awareness of caregivers' about the feeding needs of sick children, traditional beliefs/behaviours and/or suboptimal counselling and support by health workers. As a result, many children are fed lower quantities of complementary foods and/or are fed less frequently when they are sick. Mothers/caregivers often turn to family/community elders and traditional/non‐qualified practitioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours guide the use of ‘special’ feeding practices, foods and diets for sick children. A significant proportion of mothers/caregivers turn to the primary health care system for support but receive little or no advice. Building the knowledge, skills and capacity of community health workers and primary health care practitioners to provide mothers/caregivers with accurate and timely information, counselling and support on IYCF during and after common childhood illnesses, combined with large‐scale communication programmes to address traditional beliefs and norms that may be harmful, is an urgent priority to reduce the high burden of child stunting in South Asia.


Introduction
About a quarter (26%) of the world's children under five live in South Asia. Thirty-eight per cent of them have stunted growth (UNICEF 2015). Stunting, or linear growth retardation during early childhood, is an outcome of biological and/or psychosocial deprivation (Stewart et al. 2013). The short-term and long-term consequences of stunting include impaired survival, physical growth and cognitive development in preschool age children; poor school readiness, school enrolment and learning outcomes in school-age children; increased risk of obstetric complications and mortality in women; and reduced height, productivity and earnings in adults (Grantham-McGregor et al. 2007;Walker et al. 2007; de Onis et al. 2013).
A significant proportion of stunting can happen prenatally. However, evidence indicates that most stunting in low-income and middle-income countries occurs during the first 24 months of life as a result of suboptimal breastfeeding and complementary feeding practices, often in combination with recurrent infections (Stewart et al. 2013;Jones et al. 2014). Furthermore, children's nutritional status can deteriorate rapidly during/after illness if the additional nutrient requirements associated with illness/convalescence are not met and nutrients are diverted from growth and development towards the immune response. Children's poor appetite induced by illness can contribute to perpetuate the vicious cycle of infection and stunting (Brown 2003;Ramachandran & Gopalan 2009;Gulati 2010;Neumann et al. 2012;Richard et al. 2014). Additionally, in low-income and middle-income countries, infant and young child feeding (IYCF) practices during and after common childhood illnesses can be particularly poor owing to harmful traditional practices and the low coverage/quality of primary health care services (Bhutta & Salam 2012;de Onis et al. 2012;Stewart et al. 2013).
Recognizing the importance of optimal IYCF practices for child survival, growth and development, the World Health Organization (WHO) launched in 2003 the Global Strategy for Infant and Young Child Feeding and issued in 2003 the Guiding Principles for Complementary Feeding of Breastfed and Non-Breastfed Children (WHO/UNICEF 2003;WHO 2003a,b). These global frameworks highlight the importance of optimal IYCF practices during and after common childhood illnesses such as diarrhoea and pneumonia and emphasize the need to increase fluid intake during illness while feeding is maintained and increase food intake during convalescence. In addition, appropriate IYCF during and after illness is part of the WHO-led Global Strategy for the Integrated Management of Childhood Illnesses (WHO 2005). The definition and measurement of the indicators for assessing IYCF practicesbeyond the scope of this paperare comprehensively detailed elsewhere (WHO 2008(WHO , 2010. In South Asia, 1 breastfeeding is a quasi-universal practice. An estimated 96% of children are breastfed at some point in their lives, and most (80%) continue to be breastfed at 2 years of age (Dibley et al. 2010;UNICEF 2015). However, data from household surveys across the region indicate that the majority of South Asian children are not fed as per the internationally agreed upon recommendations: only a quarter (27%) of newborns start breastfeeding within 1 h of birth; less than half (48%) of infants 0-5 months old are exclusively breastfed; only about half (56%) of infants 6-8 month olds are fed soft, semi-solid or solid foods; and a mere 21% of children 6-23 months old are fed a diet that meets the minimum requirements in terms of feeding frequency and diet diversity (Senarath et al. 2012;UNICEF 2015). In view of this situation, researchers and practitioners have not hesitated to refer to IYCF in South Asia as a crisis . There is evidence that the incidence and severity of common childhood diseases are high in this region (Walker et al. 2013). However, less is known about IYCF practices during and after common childhood illnesses in South Asia.

Key messages
• Information on infant and young child feeding (IYCF) behaviours and practices during common childhood illnesses in South Asia is limited. Information of IYCF after illnesses is virtually inexistent. The evidence available indicates that IYCF practices during common childhood illnesses are far from optimal.
• When sick, most children (up to 98%) continue to be breastfed although a significant proportion (up to 49%) is breastfed less frequently than usual. Few sick children (<20%) are breastfed more frequently than usual, as is recommended, to compensate for the additional fluid and nutrient requirements associated with illnesses.
• When sick, many children (up to 75%) see their complementary foods restricted in frequency, quantity and/or quality owing to children's anorexia (perceived or real), lack of awareness of caregivers' about the feeding needs of sick children, traditional beliefs or suboptimal counselling and support by health workers.
• In general, health providers do not advise mothers to increase breastfeeding frequency while encouraging sick children to eat soft, varied and favourite foods during illness, as is recommended. Important policy, programme and capacity gaps exist with respect to IYCF for children during and after common childhood illnesses in many South Asian countries. 1 For the purpose of this paper, South Asia refers to the eight member countries of the South Asia Association for Regional Cooperation, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka.
Thus, the objective of this paper is threefold: (1) document the current IYCF practices during and after common childhood illnessesparticularly diarrhoea, fever and pneumoniaand their trends since 1990 in South Asia; (2) document caregiver's behaviours and health providers' practices with respect to IYCF during and after common childhood illnesses in South Asia; and in light of the preceding objectives, (3) identify priorities in terms of policy formulation, programme design, research and advocacy to protect, promote and support optimal IYCF practices during and after common childhood illnesses in South Asia post 2015.

Methods
We reviewed data and information from two primary sources: Demographic Health Surveys (DHS) and peer-reviewed publications. DHS collects information on care-seeking and care-giving practices during diarrhoea, fever and pneumonia using standardized sampling methodologies, interview tools and data analyses procedures, with minor country-specific adaptations. We reviewed the national DHS surveys conducted in South Asia between 1990 and 2014 to document the prevalence of common childhood illnessesdiarrhoea, fever and pneumoniain children 0-23 months old, the frequency and type of medical advice that caregivers sought, the type of treatment and/or advice that children received and how children were fed during common childhood illnesses. For countries with two data points, trends in IYCF practices during and after common childhood illness were estimated as well as the average annual rate of improvement to quantify the average improvement in a given indicator per year between the base year and end year.
The PubMed search identified 367 publications with one or more of the search terms in the title and/or abstract. In-depth scrutiny of the titles excluded 158 publications as not relevant to our review and identified 209 as potentially relevant.
In-depth scrutiny of the abstracts of these 209 publications excluded 126 as not relevant to our review and identified 83 as likely relevant. Lastly, full-text scrutiny of these 83 publications excluded 54 as not relevant to our review and identified 29 articles that were relevant to our review. In addition, we reviewed the bibliographic references of these 29 papers to identify any additional publication that could have been missed by our online search and found three additional publications that were relevant to our analysis. Hence, 32 publications were included in our analysis as they focused specifically on IYCF practices during diarrhoea, fever and/or pneumonia in South Asian countries (Fig. 1).
In addition, we conducted interviews with 13 key informants. The purpose of the key informant interviews was not to collect key informants' views, opinions or recommendations but rather to help the authors of the paper identify the existing national policies, guidelines and programmes related to IYCF during and after common childhood illnesses in the eight countries included in the analysis. In the five large countries (Afghanistan, Bangladesh, India, Nepal and Pakistan), we interviewed two UNICEF staff by country, namely the Chief of Health and the Chief of Nutrition, while in the three smaller countries (Bhutan, Maldives and Sri Lanka), we interviewed one UNICEF staff per country, namely the Chief of the Health and Nutrition programme. This made a total of 13 key informants who in turn consulted with relevant national counterparts to complete the information-gathering process.

Findings
Household survey evidence on infant and young child feeding and care practices during and after illness Six countries -Bangladesh, India, Maldives, Nepal, Pakistan and Sri Lankahad at least one DHS survey that included information on common childhood illnesses and IYCF practices (Afghanistan's 2010 DHS did not include data collection on child morbidity, and no DHS survey was available for Bhutan). DHS survey data indicate that in the countries included in the analysis, children 0-23 months old suffer from common childhood illnesses frequently. Up to 20-30% of the mothers/caregivers interviewed reported that their children had suffered from diarrhoea or pneumonia in the 2 weeks prior to the survey. The prevalence of common childhood illnesses diarrhoea, fever and pneumoniawas highest in Pakistan. In all countries, the prevalence of fever was higher than the prevalence of diarrhoea or pneumonia. Similarly, in all countries, the prevalence of common childhood illnesses was lowest during the exclusive breastfeeding period (0-5 months) and highest during the early complementary feeding period (6-11 months) (Table 1). The proportion of caregivers who sought medical advice in the event of diarrhoea was highest in India and Pakistan (>60%); the proportion of caregivers who sought medical advice in the event of fever was highest in Maldives and Sri Lanka (>80%); lastly, the proportion of caregivers who sought medical advice in the event of pneumonia was highest in India and Pakistan (>65%). The lowest proportion of caregivers seeking medical advice for common childhood illnesses was recorded in Bangladesh (30.1%, 31.4% and 41.4% for diarrhoea, fever and pneumonia, respectively (Table 2).
Data on the type of treatment/care provided to children 0-23 months old who experienced diarrhoea, fever or pneumonia in the 2 weeks preceding the survey and for whom advice or treatment was sought from a health facility or health provider were available for Bangladesh, India, Nepal and Pakistan. The proportion of children who received oral rehydration solutions (ORS) or increased fluids was highest in Bangladesh (>75%) and lowest in India (<20%) ( Table 3). Similarly, the proportion of children who received antibiotic therapy for the treatment of fever and pneumonia was highest in Bangladesh (>66%) and lowest in India (<15%) ( Table 4).
In these four countries -Bangladesh, India, Nepal and Pakistan -DHS information on IYCF practices during/after common childhood illnesses focused only on feeding practices during diarrhoea (Table 5). No information was available on IYCF practices when children had fever or pneumonia or after episodes of diarrhoea, fever or pneumonia. The proportion of  mothers/caregivers who fed their children more/same fluids as usual was highest in Bangladesh (72.6%) and lowest in India (Table 5). We were able to examine time trends in four countries -Bangladesh, India, Nepal and Pakistan, where three DHS surveys were available for the period 1990-2014. Bangladesh and Nepal made significant progress in reducing the prevalence of diarrhoea, fever and pneumonia in children 0-23 months old, mirrored by significant increases in care-seeking behaviour for these common childhood illnesses. Improvements in India were low to nil, while surveys in Pakistan reported a significant deterioration (Table 6). Table 7 summarizes the trends in feeding and care practices for children 0-23 during diarrhoea episodes. Over the 1990-2014 period, the proportion of children with diarrhoea who were given Oral Rehydration Solution (ORS) increased in Bangladesh, India and Nepal, while there was no improvement in Pakistan. The proportion of children who were not given ORS/ recommended home fluids/increased fluids declined in all countries. The highest average annual rate of reduction was recorded in Bangladesh (0.41) and the lowest in India (0.11). Detailed information on trends in IYCF during diarrhoea was available only for Nepal (2006( ) and Pakistan (2007. In both countries, most mothers reported that the amount of liquids offered to their infants during the diarrhoea episode was 'same as usual' in both base year and end year. Only about half the mothers in Nepal and one-third of mothers in Pakistan reported that the amount of food offered to their children was 'same than usual'with no improvement between base year and end year.
Research evidence on caregivers' behaviours and health providers' practices on infant and young child feeding during and after common childhood illnesses The bibliographic search identified 32 peer-reviewed publications that met the inclusion criteria for this review. One study (3%) was from Nepal, eight studies (25%) were from Bangladesh, seven studies (22%) were from Pakistan and 15 studies (47%) were from India. Table 4. Among children 0-23 months old who experienced fever or pneumonia in the 2 weeks preceding the survey and for whom advice or treatment was sought from a health facility or health provider, percentage according to the type of treatment/care that they were provided during the fever/pneumonia episode (South Asia, Demographic and Health Surveys) The majority of the studies (n = 31; 97%) reported IYCF practices during common childhood illness, while only one study reported IYCF practices both during and after illness.
Thirty studies (94%) reported IYCF practices for children with diarrhoea, eight studies (25%) reported IYCF practices for children with pneumonia and five studies (16%) reported IYCF practices for children with fever. Most studies (n = 29; 91%) reported caregivers' IYCF behaviours when children were sick, while only six studies (19%) reported health providers' IYCF counselling to mothers of sick children. Twenty-eight (88%) were observational studies. Only four (13%) studiesone in Bangladesh and three in Indiaassessed the impact of one or more interventions to improve IYCF practices during/after illness.
The findings of our review are organized around the seven key focus areas (Table 8).

Breastfeeding during and after common childhood illnesses
Sixteen studies (50%) investigated whether children continued to be breastfed while they were sick. All the studies reported that most mothers (range 69.7-98.0%) Table 5. Percentage distribution of children 0-23 months old who had diarrhoea in the 2 weeks preceding the survey by amount of liquids and food offered during the diarrhoea episode compared with normal practice as reported by the mother/primary caregiver (South Asia, Demographic and Health Surveys)

Bangladesh 2011
India 2006  continued to breastfeed their sick children irrespective of children's age or the nature of their illness (Huffman & Combest 1990;Malik et al. 1991;Badruddin et al. 1991Badruddin et al. , 1997Singh 1994;Piechulek et al. 1999 (3) the belief that breast milk had become harmful to the child because of mystical/evil forces and/or that the illness had been transmitted by the mother to the child through mother's milk (three studies) Kaushal et al. 2005;Benakappa & Shivamurthy 2012). Two studies reported that a significant proportion of mothers (range 35-61%)particularly among those with young infants 0-11 months old and/or children with diarrhoeaswitched back to predominant or Table 6. Percentage of children 0-23 months old who experienced diarrhoea, fever or pneumonia in the 2 weeks preceding the survey and for whom advice/treatment was sought from a heath facility or health provider (Demographic Health Surveys, 1990-2013  exclusive breastfeeding when children were sick Shah et al. 2011).

Fluid intake during and after common childhood illnesses
Ten studies (31%) investigated whether children continued to be given fluids when they experienced common illnesses and/or whether fluid intake increased or decreased when children were sick. Nine studies reported that most mothers (range 40-92%) continued to administer fluids to their sick children (Kaur & Singh 1994;Piechulek et al. 1999;Gupta & Gupta 2000;Agha et al. 2007;Gupta et al. 2007;Dongre et al. 2010;Memon et al. 2010;Das et al. 2013). Two Infant feeding during and after illness in South Asia   including breastmilk.

Infant feeding during and after illness in South Asia
BF, breast feeding; ARI, acute respiratory inspection; NA, not applicable.

Infant feeding during and after illness in South Asia 61
studies reported that some mothers (range 6-28%) gave additional liquids/fluids to their children during illness Das et al. 2013). Three studies reported that, in addition to water, mothers fed sick children home-made fluids such as watery porridges made from maize, rice or wheat; soups; sugar-saltwater solutions; and/or yogurt (Gupta & Gupta 2000;Gupta et al. 2007;Das et al. 2013). Six studies reported that mothers restricted the amount of liquids/fluids given to sick children (Kaur & Singh 1994;Piechulek et al. 1999;Agha et al. 2007;Ansari et al. 2009;Das et al. 2013). Fluid restriction was more frequent during diarrhoea episodes (range 4-87%) (Kaur & Singh 1994;Piechulek et al. 1999;Agha et al. 2007;Das et al. 2013) than during episodes of fever or pneumonia (range 8.3-15%) Gupta & Gupta 2000;Agha et al. 2007). Only one study reported the reasons given by mothers for restricting children's fluid intake during sickness ); these were: (1) the belief that fluids could not be absorbed during diarrhoea and thus were harmful; and (2) the perception that a reduction in the stool volume in children with diarrhoea was an improvement of the child's condition. Two studies reported that the proportion of mothers who were aware that children need more fluids during sickness ranged between 40% and 47% Memon et al. 2010).

Complementary foods and feeding practices during and after common childhood illnesses
Twenty studies (63%) investigated whether children were fed lower, similar or larger amounts of soft, semi-solid or solid foods when they suffered from common childhood illnesses. Thirteen studies reported Table 9. Policies and programmes related to infant and young child feeding (IYCF) during and after illness in South Asian countries  Afghanistan Bangladesh Bhutan India Nepal Maldives Pakistan

Sri Lanka
A national stand-alone policy for the protection, promotion and support of optimal IYCF practices is available A national nutrition and/or food security policy that includes IYCF is available The national IYCF/national nutrition/food security policy includes IYCF during and after illness A national programme for the protection, promotion and support of optimal IYCF practices exists National guidelines for the protection, promotion and support of optimal IYCF practices are available National guidelines for the protection, promotion and support of optimal IYCF include IYCF during and after illness The national training package for IYCF protection, promotion and support includes IYCF during/after illness The national guidelines for IMCI include guidance on feeding children when they are sick The national guidelines for IMCI include guidance on feeding children after being sick The national training package on IMCI includes guidance on IYCF during and after illness Phalke 2014); (5) mothers' belief that withholding certain foods would help to cure diarrhoea whereas introducing normal foods before the child was cured would have a detrimental effect on the development of the child or would lead to a 'big belly' (three studies: Mishra et al. 1990;Ahmed et al. 1992;Zeitlyn et al. 1993); and/or (6) the belief that restricting food intake was a first measure to manage diarrhoea at home and reduce the frequency of loose stools (five studies: Mishra et al. 1990;Zeitlyn et al. 1993;Piechulek et al. 1999;Dongre et al. 2010). Two studies that measured food intake in sick children 6-23 months old reported that the mean energy intake of children was significantly lower than that of healthy children and up to 70% below WHO recommendations Benakappa & Shivamurthy 2012). Two studies reported that some mothers (range 10-30%) ceased feeding their child for 24 h or longer following medical advice, because mothers perceived that the children had poor/no appetite and/or because social norms advised 'to keep bowels at rest' Piechulek et al. 1999). None of the studies reported an increase in children's food intake (frequency, quantity and/or quality). Only four studies assessed mothers' knowledge about the feeding needs of sick children; few mothers (range 17-38%) recognized the importance of feeding sick children nutritious diets comprising vegetables, pulses, small fish and/or other nutrient-rich foods Piechulek et al. 1999;Agha et al. 2007;Benakappa & Shivamurthy 2012).

Traditional beliefs and their role in IYCF during and after common childhood illnesses
Thirteen studies (41%) explored the importance of traditional beliefs and perceptions on IYCF practices during and after common childhood illnesses. Nine studies reported that when children were sick, caregivers (range 13-98%) replaced children's usual diets with 'special diets' owing to the belief that children's usual diets need to be modified to aid digestion 'because intestines become weak' Ahmed et al. 1992;Zeitlyn et al. 1993;Dongre et al. 2010;Benakappa & Shivamurthy 2012;. Young children were often fed home remedies, herbal medicines and teas, and 'soft foods' in the form of soups and gruels Zeitlyn et al. 1993;Piechulek et al. 1999;Gupta & Gupta 2000;Dongre et al. 2010;Benakappa & Shivamurthy 2012; because they were perceived to 'be lighter on the stomach', 'be easier to digest', 'reduce abdominal pain' and/or 'diminish the frequency of stools'. Conversely, foods like fish, milk, meat, food items containing oil or even vegetables were avoided because they were considered 'difficult to digest' or 'too heavy to digest' Zeitlyn et al. 1993;Piechulek et al. 1999;. Seven studies Zeitlyn et al. 1993;Piechulek et al. 1999;Rashid et al. 2001;Dongre et al. 2010;Benakappa & Shivamurthy 2012; reported that caregivers avoided giving specific 'hot' or 'cold' foods to sick children because these foods were considered inappropriate for certain diseases. Foods commonly avoided in case of diarrhoea were eggs/meat (range 25% to >95%), roti/chapatti/wheat flour breads (~70%) and milk (47-50%); in case of pneumonia, commonly avoided foods were fish/duck/pigeon (>90%) or curd/buttermilk (range 76% to 93%); in case of fever, commonly avoided foods included rice (40%) and curd/butter milk (range 60-70%). Two studies reported that some caregivers (range 16-23%) avoided giving sick children foods like fish, meat or eggs because 'they attract evil forces' and thus they were harmful to children Piechulek et al. 1999).

Community elders/traditional practitioners' advice on IYCF during/after childhood illnesses
Five studies (16%) reported on the role of mothers-inlaw (four studies: Zeitlyn et al. 1993;Rashid et al. 2001;Kaushal et al. 2005;Gupta et al. 2007) or other family elders ) on decision regarding IYCF practices when children were sick. Common advice given by family elders to mothers when children were sick included the following: (1) to opt for home remedies as a first line of treatment Gupta et al. 2007); (2) to accept children's refusal to eat/be fed as 'normal' and delay feeding by one day (Kaushal et al. 2005); and/or (3) to refrain from giving sick children certain foods such as fish, meat, vegetables or milk . Nine studies (28%) reported that a varying proportion of mothers (range 5.3-84%) sought help from traditional/unqualified practitioners when their children were sick Rashid et al. 2001;Bharti et al. 2006;Dongre et al. 2010;Shah et al. 2011;Hirani 2012;Das et al. 2013). However, only one study described the role of traditional/unqualified practitioners on IYCF counselling to mothers when children were sick . This study reported that traditional/ unqualified practitioners advised mothers to restrict children's food intake; however, it did not provide specific details on the types of foods that a mother should avoid when her child was sick.

Health professionals' advice on IYCF during and after common childhood illnesses
Six studies (19%) investigated the role of health professionals in providing IYCF advice to mothers when children were sick Kasi et al. 1995;Badruddin et al. 1997;Piechulek et al. 1999;Benakappa & Shivamurthy 2012). In general, health professionals gave little or no advice to mothers on how to feed their children during or after the illness episode: three studies reported that health providers (range 46-100%) advised mothers to continue breastfeeding Badruddin et al. 1997;Piechulek et al. 1999); two studies reported that health providers (range 9-71%) advised mothers to give oral rehydration solution/home-based fluids to infants and young children suffering from diarrhoea Kasi et al. 1995). No study reported that health providers advised mothers to increase fluid intake when children were sick. Similarly, no study reported that health providers advised mothers to encourage their sick children to eat soft, varied and favourite foods during illness, as recommended by WHO (WHO 2003a, 2003b. Conversely, two studies  reported that health providers advised mothers (proportion not reported) to withhold breast milk and foods such as rice and buttermilk (in case of diarrhoea), rice (in case of fever) or cold foods like curd, buttermilk, fruit juices and bananas (in case of pneumonia or acute respiratory infections). Two studies reported that health professionals (range 7-62%) advised mothers to feed their children soft and semi-solid foods only after children had recovered from the illness (Kasi et al. 1995;Benakappa & Shivamurthy 2012).
Interpersonal and group counselling on IYCF during/after common childhood illnesses Three studies (9%)all in Indiareported the impact of behaviour change communication interventions on mothers' IYCF practices when children had diarrhoea (Kaur & Singh 1994;Mangala et al. 2000). Two studies reported the impact of home visits and group counselling by trained community health workers. In these studies, the proportion of mothers giving 'less than usual' amounts of food to their sick children declined from 98% to 35% and from 55% to 29% (Kaur & Singh 1994;. The third study assessed the impact of cooking demonstrations using locally available foods and interpersonal counselling sessions on mothers' IYCF practices when children were sick . The results of the intervention indicated the following: (1) the proportion of mothers who breastfed more frequently while children had diarrhoea increased from 15% to 47%; (2) the proportion of mothers who modified family foods to make them soft and digestible (i.e. more palatable) increased from 2% to 26%; and (3) the proportion of mothers who fed their children additional food for at least 2 weeks after the diarrhoea episode increased from 0% to 20%.
Review of national policy and programme frameworks for infant and young child feeding during and after common childhood illnesses We reviewed national policy and programme documents to assess whether national frameworks for maternal and child nutrition integrate IYCF during and after illness. In addition, we conducted interviews with 13 key informants to document the existing national programmes that protect, promote and support optimal IYCF practices for children during and after illness ( Table 9).
Five of the eight countries have a national IYCF policy, either as a stand-alone policy framework on infant feeding or as part of a larger policy framework on nutrition/food security. However, only two countries -India and Nepalhave integrated the feeding needs of children during and after illness in their IYCF policy framework.
All countries have national guidelines on IYCF, and seven countries have a national programme for the protection, promotion and support of optimal IYCF. However, only five countries include in their national IYCF guidelines guidance on how children should be fed during and after illness, and only five countries have developed a training package on IYCF for programme staff that includes IYCF for children during and after illness.
All countries have a national programme for the integrated management of childhood illnesses (IMCI); six countries have national IMCI guidelines that include guidance on feeding children during and after illness; however, only four countries have developed an IMCI training package that includes guidance on how to feed children when they are sick and after being sick.

Discussion
We conducted a comprehensive review of the available evidence on IYCF practices during and after common childhood illnessesdiarrhoea, fever and pneumonia in South Asia (1990Asia ( -2014 to inform policy formulation, programme design, advocacy and research prioritization to protect, promote and support optimal IYCF practices during and after common childhood illnesses in South Asia post 2015. Demographic Health Survey data on IYCF during common childhood illnesses were available only for Bangladesh, India, Nepal and Pakistan, which are home to~96% of the children under 5 years of age in South Asia (UNICEF 2015). Similarly, the 32 publications that met the inclusion criteria of our review focused on these four countries. Furthermore, the available DHS data in these four countries were limited to IYCF during diarrhoea episodes. No survey data were available on IYCF practices after episodes of diarrhoea or during/after episodes of fever or pneumonia. Similarly, the published research was primarily focused on IYCF practices during diarrhoea and to a lesser extent during fever or pneumonia episodes. Research evidence on IYCF after common childhood illnesses was practically inexistent.
Demographic Health Survey data indicate that in the countries included in the analysis, children 0-23 months old suffer from common childhood illnesses frequently, as nearly one-third of the mothers/caregivers reported that their children had suffered from diarrhoea or pneumonia in the 2 weeks prior to the survey. These findings are in line with reports indicating that 39% of child deaths in South Asia are due to diarrhoea and/or pneumonia (UNICEF 2012). Importantly, DHS data indicate that in all the countries included in our review, the occurrence of diarrhoea, pneumonia and fever was lowest during the exclusive breastfeeding period (0-5 months) and highest during the early complementary feeding period (6-11 months). This is most likely due to the well-documented protective benefits of exclusive/ predominant breastfeeding in the first 6 months of life and the higher levels of infection in late infancy and early childhood due to children's increased intake of complementary foods and fluids that may be contaminated as well as the ingestion of faecal bacteria through mouthing soiled fingers or household items when children begin to crawl and explore their environment (Kosek et al. 2003;Dewey & Mayers 2011;WHO 2013).
Our review shows that in South Asia, IYCF behaviours and practices during common childhood illnesses are far from optimal. Most infants and young children continue to be breastfed when they are sick; however, few children (<20%) are breastfed more frequently as recommended. Studies in other settings have reported a similar practice, as most mothers continue to breastfeed their sick children without altering the number of nursing episodes, total amount of time of suckling or energy derived from breast milk (Hoyle et al. 1980;Brown et al. 1990;Martz & Tomkins 1995;Brown 2003).
Similarly, most sick children continue to be fed fluids. However, few children (range 7.4-21.7% in Pakistan and Bangladesh, respectively) were fed fluids more frequently as recommended. Mothers' awareness about children's need for more fluids during sickness is low. This evidence is in line with reports indicating that in developing countries, less than a quarter (22%) of children are fed more fluids during illness (UNICEF/WHO 2009). Conversely, a significant proportion of mothers/caregivers in Bangladesh (26.7%), Pakistan (37.9%) and India (42.2%) fed their sick children less fluids than usual or no fluids at all in contrast with reports from other countries (Bani et al. 2002;Saha et al. 2013).
We find that food restrictions are frequent. Many children were fed lower quantities and/or less frequently when they were sick. As many as 36% of mothers/caregivers in Bangladesh, 41% in Pakistan and 43% in India reported that they fed their children less food than usual or no food at all during the last diarrhoea episode. Only one-third (34%) of the mothers/ caregivers in India to about half (55%) in Nepal reported that they fed their children same/similar amounts of food as usual during the diarrhoea episode. Studies in Latin America have indicated that anorexia is an important factor in the reduction of children's dietary intake during illness (particularly when diarrhoea or fever are present) as mothers/caregivers tend to give in when sick children send a 'food reject' signal (Bentley et al. 1991(Bentley et al. , 1995. The combined effects of anorexia and tradition-driven withdrawal of complementary feeding during common childhood illnesses can be devastating (Scrimshaw & Sangiovanni 1997).
Our review indicates that in South Asian countries, mothers'/caregivers' knowledge about the feeding needs of sick children is limited and that feeding practices are often guided by traditional beliefs and norms that encourage the use of 'special' foods/diets to replace 'usual diets' when children are sick. Similarly, many caregivers seem to avoid giving certain 'hot' or 'cold' foods to sick children because these foods are considered inappropriate for specific diseases. Studies have reported that deeply held beliefs and traditions determine the types of foods or preparation methods that are 'healthy' or 'unhealthy' for sick children, when and what types of complementary foods are given to children and how to feed children who are sick and/or do not want to eat. These beliefs are heavily influenced by the individuals who surround mothersthat is, husbands, mothers-in-law, grandmothers and other family/community membersand the health care providers upon whom caregivers depend for support (Martz & Tomkins 1995;Stewart et al. 2013).
Care-seeking practices in South Asia are said to be below global estimates for low-income and middleincome countries (Walker et al. 2012). However, the latest DHS data available for the countries included in our review indicate that a significant proportion of mothers/caregivers (ranging from 30% to 84% depending on country and illness) took their sick children for medical advice during the last episode of diarrhoea, fever or pneumonia. Our review shows that few published studies have investigated the quality of health providers' counselling on IYCF to mothers/ caregivers when children are sick. The evidence reviewed indicates that when mothers/caregivers seek advice/support in the primary health care system, health professionals provide little or no advice to mothers/caregivers on how to feed children when they are sick/convalescent. In general, health providers do not advise mothers to increase children's fluid intake and encourage sick children to eat soft, varied and favourite foods during illness, while increasing breastfeeding frequency as is recommended. Moreover, there is indication that a non-negligible proportion of health providers advise mothers to withdraw breast milk and/or specific nutritious foods/all complementary foods until children recover from illness.
Studies in other low-income and middle-income countries have found the following: (1) health workers do not maximize their contacts with women and children to support optimal IYCF; (2) there is poor knowledge among health practitioners on how to feed and/or manage sick children and manage children with poor appetite; (3) even when a national normative and guidance frameworks on IYCF for sick children are in place, a limited proportion of paediatricians and family practitioners follow them; and (4) the quality of care and advice among private practitioners is not necessarily better than among public health system providers (Bezerra et al. 1992;Bojalil et al. 1998;Baker et al. 2013;Lutter et al. 2013).

Conclusion
Diarrhoea and pneumonia remain the leading infectious causes of childhood morbidity and mortality in South Asia (Fischer et al. 2013). Compelling evidence indicates that childhood diarrhoea and pneumonia deaths are avoidable and that scaling up optimal feeding behaviours and practices in combination with appropriate case management can avoid most of these deaths .
Our review shows that information of IYCF behaviours and practices during illnesses in South Asia is limited while information of IYCF after common childhood illnesses is virtually inexistent. The evidence reviewed indicates that in South Asia, IYCF behaviours and practices during common childhood illnesses are far from optimal. In general, sick children continue to be breastfed. However, few are breastfed more frequently to compensate for the additional fluid and nutrient requirements associated with illnesses, while a significant proportion of children is breastfed less frequently than usual. Restriction or withdrawal of complementary foods during illness is frequent because of children's anorexia (perceived or real), poor awareness by caregivers' about the feeding needs of sick children, traditional beliefs and behaviours, and/or suboptimal counselling and support by health workers. As a result, many sick children are fed less frequently and/or lower quantities of complementary foods.
Mothers/caregivers often turn to family/community elders and traditional/non-qualified practitioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours often guide the use of 'special' feeding practices, foods and diets for sick children. Our review indicates that when children are sick, a significant proportion of families turn to the primary health care system for advice and support. In general, health professionals give little or no advice to mothers/caregivers on how to feed their children while they are sick. However, the few intervention studies available indicate that inter-personal and group counselling as part of primary health care can substantially improve mothers' IYCF knowledge and practices during common childhood illnesses.
Global guidance and normative frameworks are in place to address the feeding of sick children during and after illness (WHO 2003a(WHO , 2003bWHO/UNICEF 2003;WHO 2005). All the countries included in our review have national guidelines on IYCF and a national programme for the IMCI. However, there seem to be important policy, guidance and capacity building gaps in these frameworks with respect to IYCF when children are sick or convalescent. Our review indicates that a limited proportion of health practitioners follows all aspects of these guidance.
In light of our findings, it seems reasonable to recommend the following as a way forward to protect, promote and support optimal IYCF practices during and after common childhood illnesses in South Asia post 2015: 1. align national policy frameworks and programmatic guidance with internationally agreed upon recommendations on IYCF during and after common childhood illnesses, with a particular emphasis on diarrhoea, fever and pneumonia; 2. expand the DHS and National Nutrition Surveys to include quantitative information on IYCF during and after common childhood illnesses, with appropriate geographic, socio-economic and gender disaggregation; 3. collect qualitative and quantitative information on caregivers' behaviours and health workers' practices related to IYCF during and after common childhood illnesses to identify the most important drivers of current behaviours/practices and bottlenecks to optimal IYCF when children are sick/convalescent; 4. build the capacity of facility-based and communitybased health workers to provide mothers/caregivers with timely and accurate information, counselling and support on IYCF when children are sick/ convalescent; 5. design and implement effective communication strategies that combine interpersonal communication and mass communication to address harmful beliefs and norms with respect to the nutrient and feeding needs of children during/after common illnesses; and 6. document the effectiveness, impact and lessons learned of the capacity building and communication strategies to improve IYCF during and after common childhood illnesses and their implications for programme scale up and universalization.