This study is the first to examine infant and young child feeding practices among Syrian refugees and their Lebanese host communities. The findings showed suboptimal breastfeeding and complementary feeding practices among both study groups. Distinct determinants for EBF at four and 6 months among children of the Syrian refugees and those of Lebanese host communities were revealed.
The rates of early initiation of breastfeeding observed among both study groups (64.9% and 64.7% among Syrian refugees and Lebanese host communities, respectively) were similar to those observed among Turkish households and Syrian refugees in Turkey (71.1% and 61.4% respectively [26]). These rates were higher than those reported globally in 2017 (44% [27]), in the Middle East and North Africa (MENA) region in 2017 (34.3% [28]), and among Syrian refugees in Jordan in 2016 (37.1% [29]). The rural nature of this study location may explain the higher rates of early initiation of breastfeeding, as traditions encourage mothers to breastfeed early and, unless there are any medical complications, mothers are expected to take care of their newborn immediately after birth.
Concerning EBF at 6 months, results differed among the two groups studied, whereby households of Lebanese host communities reported lower rates as compared to those of Syrian refugees: 20.7% vs 50.8% respectively. The rate of EBF at 6 months among Lebanese host communities in this study (20.7%) is comparable to that of the MENA region (20.5%) [28], however it is lower than rates globally (40%) [27], in Turkey in 2020 (34.1% [26]), in the United Arab Emirates (UAE) in 2013 (25% [30]) and in Jordan in 2017 (33% [31]). As for Syrian refugees’ children, their rate of EBF at 6 months (50.8%) was higher than that reported for Syrian refugees in Turkey in 2020 (28.1% [26]) and Syrian refugees in Jordan in 2016 (19.1% [31]). The dire circumstances Syrian refugees in Akkar are facing in addition to their refugee situation may have contributed to their increased dependence on breastfeeding as the main nutrition source for their infants. On the other hand, the low rates observed among Lebanese host communities in Akkar can be attributed firstly to the perception of problems with milk production as 27.5% of Lebanese mothers reported problems with milk production as the primary reason for stopping breastfeeding, and secondly to the higher incidence of Cesarean section birth among Lebanese host communities compared with Syrian refugees in this study (35.6% vs 20.6% respectively). Cesarean section birth was reported by previous studies to be associated with a lower incidence of breastfeeding [32, 33].
Furthermore, rates of continued breastfeeding at 1 year among Lebanese host communities in this study (39.2%) are similar to those found in an earlier investigation in Lebanon in 2005 (35% [34]) and the UAE (37% [35]). These rates are however lower compared with rates globally (74% ([27] and in Turkey in 2020 (63.8% [26]). Among Syrian refugees, the rates of continued breastfeeding at 1 year (58.1%) were similar to rates among Syrian refugees in Jordan and Turkey (56.5% and 55.9% respectively [26, 31]).
Taken together, the rates related to the indicators of breastfeeding in this study indicated higher mean duration of breastfeeding and EBF among Syrian refugee households compared with households of Lebanese host communities. Lebanese households may have had the option of transferring to infant formula feeding or early introduction of solid foods and stopping breastfeeding or EBF, whereas Syrian refugee households may find it more difficult to procure foods and thus depend on breastfeeding for a longer period as the source of child nutrition. This is also seen by the lower mean age of solid or semi-solid food introduction among households of Lebanese host communities compared with Syrian refugee households indicating later initiation of complementary feeding among Syrian refugee households thus longer periods of breastfeeding and EBF.
The American Academy of Pediatrics recommends that infants not be introduced to solid foods before the age of 6 months as younger children (especially those aged less than 4 months) are not developmentally ready for solid foods [36]. Existing evidence indicated that early introduction of solids may increase the risk of some chronic diseases, such as obesity, celiac disease, eczema, and diabetes [37]. Results from this study showed that around one quarter of mothers introduced solid or semi-solid foods to their children before 6 months of age, with higher rates among households of Lebanese host communities compared with Syrian refugee households (31.4% vs 20.7% respectively). Rates of children from Lebanese host communities who were introduced to solid foods before 6 months were similar to rates globally (29%) and in the MENA region (27%) [38]. However, these rates fall below earlier estimates from Lebanon in 2010 (74.8%) [39], in Jordan in 2019 (54.3%) [40]. Reasons for the introduction of solid foods reported in this study included that the child was still hungry after milk feeds, child was old enough, and tradition in family. All these reasons are subjective and may indicate gaps of knowledge among mothers on when to appropriately initiate complementary feeding for children. Such reasons were also commonly observed in other studies in Jordan, the UAE, and the United States of America (USA) [30, 40].
Furthermore, the World Health Organization (WHO) recommends the introduction of traditional iron-fortified cereal and meat as the first complementary foods to meet the iron requirements of growing infants and decrease the risk of iron deficiency [41]. However, less than one third (29.5%) of infants in the study sample were given iron-fortified baby cereals and only 1.1% were given protein foods (iron rich foods), while 40% were given unfortified refined grains and 8.8% and 3.4% were given fruits and vegetables respectively. In addition, fried foods and high sugar foods were also reported as first foods introduced among 3.1% of infants in the study sample. The observed gap between recommendations and actual suboptimal complementary feeding practices observed in this study sample can be attributed to both food availability problems in these fragile communities as well as poor knowledge about feeding practices. The lack of knowledge about complementary feeding practices among Syrian refugee mothers in Lebanon has been previously documented and was shown to affect not only types of solid foods, but also quantities and timely initiation of solid foods [42]. These findings indicated the need for promoting infant feeding practices, not only in terms of providing financial aids but also educational programs and awareness campaigns to spread appropriate complementary feeding practices.
The MDD rates were higher among children of Lebanese host communities (45%) compared with Syrian refugees’ children (27%). These lower rates are understandable in light of the lower availability of food items among Syrian refugees and later introduction of solid foods as observed in this study. In addition, the MAD rates were extremely low among both study groups’ households (11.2% and 9.9% among Lebanese host communities and Syrian refugee households respectively). These two indicators show that dietary diversity is poor during the complementary feeding period, though poorer among Syrian refugee households. This is especially concerning, as poor dietary diversity can put infants and young children at an increased risk of inadequate intake of various essential micronutrients, especially zinc and iron [43], and may be associated with stunting as shown in many studies from low- and middle-income countries [44,45,46]. When compared with other rates, MDD rates among Lebanese children in this study (45.3%) were lower than rates observed in the UAE (71.4%) [47], but higher than rates observed globally (29.4%) and in the MENA region (16%). In addition, rates of MDD among Syrian refugees’ children in this study (27.7%) were comparable with rates among refugees from Thailand-Myanmar borders (22.3%) [48]. Given the fragility of the situation, households participating in this study do not appear to have proper access to food and thus are expected to have such low MDD and MAD rates compared with other countries.
In this study, a few factors affected the odds of EBF at four and 6 months. Given the distinct breastfeeding profile of Syrian refugees and their host Lebanese communities, these factors were examined separately. Among Syrian refugees, the education level of the father and his employment status seemed to significantly influence EBF. More specifically, a higher educational level (intermediate school or above) among fathers was found to increase the odds of EBF at 4 months among Syrian refugee mothers compared with fathers whose educational level was primary school or less. Studies from both developed and developing countries such as Sweden and Bangladesh found similar results, where a higher educational level of parents contributed to better breastfeeding [49, 50]. In addition, having an employed spouse increased the odds of EBF for 4 months among Syrian refugee mothers. A husbands’ employment, especially for long hours, is very important and is often an overlooked way in which some spouses support and enable mothers to breastfeed, particularly as the entire family depend on the income of the spouse, and this was shown in a study done in the USA [51]. A husband’s employment often frees the mother from the burden of employment that can interfere with breastfeeding, especially EBF, as work schedule and stress can affect her ability to feed a baby.
As for the Lebanese host communities, the sex of the child and delivery mode were the factors found to significantly affect EBF for four and 6 months. The odds of EBF decreased when the gender of the child was female, indicating a possible preference of mothers to care for boys rather than girls. However, findings from another study in India showed that girls were exclusively breastfed more than boys. Interestingly, in the latter study, it seemed that mothers valued the health of boys more than girls, therefore they interrupted EBF earlier to increase intake of boys from other nutritious sources (solid foods) [52]. Taken together, the findings of this study and others underscored the need to account for gender when examining breastfeeding and complementary feeding practices. Furthermore, natural birth was found to increase the odds of EBF for 6 months among mothers of the Lebanese host communities. Such a finding was also observed in other studies in Lebanon, Jordan, Ethiopia, and Bangladesh where obstetric complications that may occur before and after Cesarean section are believed to interfere with breastfeeding, and the wound pain and anesthesia of the Cesarean section are thought to contribute to poor child nursing practices [40, 50, 53, 54].
Some limitations need to be considered when interpreting the results of this study. First, the inability to generalize the results to the whole Lebanese host and Syrian refugee communities, as Akkar represents a rural and impoverished area in Lebanon. However, the adequate sample size allows for the generalization of the data to similar communities. Another important limitation is that breastfeeding practices were self-reported, and the study is retrospective in nature and thus subject to social desirability and recall bias and misreporting. It should be noted however, that all interviews were conducted by trained dietitians who followed standardized techniques and procedures to ensure optimal collection of required data. Furthermore, it is noteworthy to indicate that the questionnaire used was not formally validated in the context of the study. That said, a panel of experts, consisting of a dietitian, a public health nutritionist and a nutrition epidemiologist, examined the face validity of the questionnaire. The content validity was further confirmed during the pilot-testing phase (described earlier in the Methods section). In addition, the cross-sectional nature of the study may suggest associations and does not establish causality.