What influences child feeding in the Northern Triangle? A mixed-methods systematic review

Optimising child feeding behaviours could improve child health in Guatemala, Honduras and El Salvador, where undernutrition rates remain high. However, the design of interventions to improve child feeding behaviours is limited by piecemeal, theoretically underdeveloped evidence on factors that may influence these behaviours. Between July 2018 and January 2020, we systematically searched Cochrane, Medline, EMBASE, Global Health and LILACS databases, grey literature websites and reference lists, for evidence of region-specific causes of child feeding behaviours and the effectiveness of related interventions and policies. The Behaviour Change Wheel was used as a framework to synthesise and map the resulting literature. We identified 2,905 records and included 68 relevant studies of mixed quality, published between 1964 and 2019. Most (n = 50) were quantitative, 15 were qualitative and three used mixed methods. A total of 39 studies described causes of child feeding behaviour; 29 evaluated interventions or policies. Frequently cited barriers to breastfeeding included mothers' beliefs and perceptions of colostrum and breast milk sufficiency; fears around child illness; and familial and societal pressures, particularly from paternal grandmothers. Child diets were influenced by similar beliefs and mothers' lack of money, time and control over household finances and decisions. Interventions (n = 22) primarily provided foods or supplements with education, resulting in mixed effects on breastfeeding and child diets. Policy evaluations (n = 7) showed positive and null effects on child feeding practices. We conclude that interventions should address context-specific barriers to optimal feeding behaviours, use behaviour change theory to apply appropriate techniques and evaluate impact using robust research methods.