Simple, valid, and reliable indicators are crucial to track progress and guide investment to improve nutrition and health during the first 2 years of life. Indicators that assess breastfeeding are useful to monitor trends, to develop and evaluate programmes, and for advocacy.¹ Until now, however, we have lacked indicators for population-based surveys to measure feeding practices for children 6–24 months of age. Limited knowledge on the scale and distribution of inadequate feeding practices and consequences for children’s survival, health, and physical and mental development has hampered investment and action to improve these practices, as argued by Jennifer Bryce and colleagues in last week’s Lancet.²

The development of indicators for child-feeding practices poses conceptual and analytical challenges in that these practices are multidimensional, inter-related, and change rapidly within short age-intervals.³ Unlike exclusive breastfeeding, which can be summarised in a single indicator, the measurement of feeding practices for children aged 6 months and older involves assessing various dimensions simultaneously. These dimensions include continued breastfeeding, appropriate timing of introduction of complementary foods, and optimum quantity and quality (micronutrient density) of the foods consumed.

With the scientific rationale for the various dimensions of child feeding defined for breastfed⁴ and non-breastfed children,⁵ WHO and partners developed indicators to assess child feeding for the ages 6–24 months and updated the breastfeeding indicators.³, ⁶, ⁷ Partners were the International Food Policy Research Institute, the Food and Nutrition Technical Assistance Project at the Academy of Educational Development, Macro International, the University of California at Davis, the US Agency for International Development, UNICEF, and a group of collaborating researchers.

This 5-year effort resulted in a set of core and optional indicators. The former include new indicators for dietary diversity (a proxy for nutrient-density adequacy), feeding frequency (a proxy for adequate energy intake from food), and consumption of iron-rich or iron-fortified foods among breastfed and non-breastfed children aged 6–24 months. The indicators focus on selected food-related dimensions of child feeding that can be measured in large surveys. Other dimensions of optimum feeding, such as responsive feeding and adequate texture of food, are likely to require more complex measurement approaches. The core list also includes previously used breastfeeding indicators and updated indicators for exclusive breastfeeding in infants aged less than 6 months and appropriate breastfeeding in children aged less than 24 months. Most of the proposed indicators can be derived from questions already in widely implemented population-based surveys, such as the Demographic and Health Surveys and UNICEF Multiple Indicator Cluster Surveys; others will require the addition of simple questions. These same questions can easily be added to other surveys.

An earlier version of these indicators showed the gravity of problems with feeding of infants and young children and the scale of the challenges ahead. For example, in 13 of 18 countries with nationally representative data in sub-Saharan Africa, less than 30% of breastfed children were fed solids or semisolids the minimum number of times and fed the minimum number of food groups.⁸ Non-breastfed children fared worse: in 14 of 18 of the same countries less than 10% received milk products in addition to being fed solids or semisolids the minimum number of times and being fed the minimum number of food groups.

The steering team of the Working Group on Infant and Young Child Feeding Indicators invites all stakeholders to share their observations and comments on the draft outline of the proposed indicators⁹ by Feb 27, 2008. The final set of indicators will be published by WHO and partners in 2008. To further harmonise and standardise assessment across countries, an operational guide on sampling and other measurement issues will be published separately.

To advance the public-health agenda to improve child survival, health, and mental and physical development, the key input of feeding practices in infants and young children must be measured and standard indicators for doing so used globally. Our proposed indicators already enjoy support from key institutions involved in child nutrition, and their revision, on the basis of public comment, will further ensure broad consensus and adoption.

Mary Arimond, *Bernadette Daelmans, Kathryn Dewey, for the steering team of the Working Group on Infant and Young Child Feeding Indicators
International Food Policy Research Institute, Washington, DC, USA (MA); WHO, 1211 Geneva 27, Switzerland (BD); University of California, Davis, CA, USA (KD)
daelmansb@who.int

The steering team of the Working Group on Infant and Young Child Feeding Indicators is: MA, Eunyong Chung, BD, KD, Chessa Lutter, José Martines, Marie Ruel, and Anne Swindale. We declare that we have no conflict of interest.

1. WHO. Indicators for assessing breastfeeding practices. WHO/CDD/SER/91.14. Geneva. World Health Organization. 1991. http://www.who.int/child_adolescent_health/documents/cdd_ser_91_14/en/index.html (accessed 31 January 2008). [Back]
2. Bryce J, Coitinho D, Darnton-Hill I, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: effective action at national level. Lancet 2008; 371: 510–26. [Back]
3. Ruel MT, Brown KH, Caulfield LE. Moving forward with complementary feeding: indicators and research priorities. Food Nutr Bull 2003; 24: 289–90. [Back]
4. Pan American Health Organization, World Health Organization. Guiding principles for complementary feeding of the breastfed child. 2003. http://www.who.int/child_adolescent_health/documents/a85622/en/index.html (accessed 31 January 2008). [Back]
5. World Health Organization. Guiding principles for feeding non-breastfed children 6–24 months of age. 2005. http://www.who.int/child_adolescent_health/documents/9241593431/en/index.html (accessed 31 January 2008). [Back]
6. Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality and energy intake of infants and young children in developing countries: summary of findings from analysis of 10 data sets. August, 2006. http://www.fantaproject.org/downloads/pdfs/IYCF_Datasets_Sep06.pdf (accessed Jan 29 2008). [Back]
7. Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality of infants and young children in developing countries: additional analysis of 10 data sets. July, 2007. http://www.fantaproject.org/downloads/pdfs/IYCF_Datasets_Sep07.pdf (accessed Feb 1 2008). [Back]
8. United States Agency for International Development. Infant and young child feeding update. September, 2006. http://www.measuredhs.com/pubs/pdf/NUT1/NUT1.pdf (accessed Jan 29 2008). [Back]
9. WHO. Indicators for assessing infant and young child feeding practices.
   http://www.who.int/child_adolescent_health/topics/prevention_care/child/ nutrition/indicators/en/index.html (accessed Jan 31 2008). [Back]