In India, malnutrition is one of the serious epidemiological problems affecting vast number of infants and children. Malnutrition related problems in developing countries like India is still causing 68% of the total deaths in the group of 6-60 months 1. The leading authorities have identified core factors which precede malnutrition that is lack of knowledge of infant and young child feeding practices and inappropriate breast feeding 2.

Complementary foods should be introduced as the child’s energy and nutrient requirements increase, and breast milk alone can no longer suffice for the continuing of optimal growth. According to WHO and UNICEF, the child is extra vulnerable in the transition when introduced to complementary feeding, and access to information on what sufficient and safe complementary feeding practices entails is important and complementary feeding should be timely, adequate, and appropriate, meaning a child should receive foods in addition to breastmilk (or formula milk) from six months and onward 3. Additionally, it is recommended that a child should receive a diverse diet, at a frequency that is age appropriate (WHO, 2009) 3. R.E Black et al mentioned that if the increasing nutrient requirements are not met, over time the child will consequently become undernourished, leading to impaired physical and cognitive development, and a child more prone to disease 4. Half of the under 5 deaths in 2018 occurred in just five countries: India, Nigeria, Pakistan, Ethiopia and the democratic Republic of Congo. India and Nigeria alone account for one third and the leading causes are diarrhoea, acute respiratory tract infection caused by inappropriate feeding practices (WHO & UNICEF, 2019) 5.

Prevalence of speech delay in India is high around 27% in children aged 1- to 3-year-old according to recent studies 6. Undernourishment leads to speech and language delay by causing delayed maturation of auditory pathways which in turn impacts hearing , oral and written language 7. However, in well nourished children, there are various biological and environment risk factors which determines oral language. One important factor is oral motoricity and chewing which starts at a very early age of 6 to 8 months by providing right textures of food at appropriate times 8. Speech development which require different oral motor skills are actually followed by different food textures 9. Solid foods aids in growing jaw, tongue and lips muscles as well as make them stronger which is requisite for speech 8.

While there is large stock of knowledge on complimentary feeding practices predicting nutritional status of under five children, there is sparcity of data on how complimentary feeding textures connects to speech development. This study seeks to complete the meagreness of knowledge by determining the relation between food textures and speech delay of 12–36-month-old Indian children, with the view that base line data will be generated. So the objectives of the study are to assess the infant and young child feeding practices and its impact on nutritional status of 12 to 36 month old children and secondly to study the speech development of 12 to 36 months of children and its association with infant feeding practices in children who are otherwise well nourished in terms of weight for age, height for age and weight for height in northern Haryana.

The present cross-sectional study was being conducted on Pediatric OPD basis in Haryana in the year 2019 in the month of January to April. We took 64 children in the age group of 12 months to 36 months who visited OPD in these four months as study subject after excluding children who were born preterm or small for gestational age, children with global development delay, chronic illnesses, hearing problems or any oro-motor congenital anomalies. Mothers of children aged 1 to 3 year who were willing to participate in the study were interviewed on a predesigned questionnaire (See Appendix A) which was printed in English after obtaining written informed consent. Appropriate time to fill the questionnaire was 10 minutes which had questions pertaining to five categories.

a) Sociodemographic characteristics of parents: mother and fathers education, their caste, religion, annual gross income.

b) Characteristics of infants and toddlers: age, gender, birth weight.

c) Breastfeeding and complimentary feeding details: time of start of breastfeeding, feeding was done breast milk, cow milk, infant formula or mixed feeding, time of start of complimentary feeding, feeding adequacy with diversity (cereals, legumes, fruits, vegetables, poultry food items) and frequency, change of texture of feeding.

d) Infants and toddler environment: nuclear or joint family, number of hours of watching television or screen time, any family history of speech delay.

e) Reasons for not giving exclusive breastfeeding till 6 months, not starting complimentary feeding by 6 months, and not changing texture of food from pureed to lumpy food by 8 months.

Feeding adequacy is assessed by MDD (Minimum diet diversity), MDF (Minimum diet frequency) and complimentary food texture according to WHO and ESPGHAN guidelines 10, 11

Prevalence of underweight, wasting and stunting in our study is 7.6 % and 9.3 % and 9.2% respectively. WHO data published in 2018 says 7.3% of the children are wasted and 21.9 % of the children are stunted 13. In India, it was revealed that under-weight , stunting and wasting among under-five children ranged from 39% to 75%, 15.4% to 74% and 10.6% to 42.3% respectively across different regions of the country 14. The lower rates of wasting and stunting in our study can be explained by the fact that we had more number of children with upper and middle socioeconomic status and 87.6 % of mothers and 84 % of fathers were graduate, post graduate or having professional degree.

Prevalance of speech delay in children in our study is 29.2% which is comparable to previous studies of speech delay in children 12 to 36 month age using LEST scale in India 6.

In our study, lower maternal education, lower annual income of parents, food diversity score less than 4 and inadequate food frequency were the core factors leading to malnutrition. Edem M.A.Tette also stated that poverty remains an important underlying cause of malnutrition 15. Joyce Nankumbi and Joshua K Mullira also concluded the fact that knowledge, culture, social status of primary caregivers are the elements behind malnutrition in children across the world 16. Previous studies also concluded that lack of knowledge and barriers of practicing complimentary feeding practices are the core factors leading to malnutrition 17. Although Malnourished children are also associated with change of texture of food (p=0.022), as most of them were on predominantly cow milk, and they were not introduced diverse diet and texture of food is definitely not considered.

Bernadette Marriott et al concluded timely introduction of complimentary feeding ,early initiation of breast feeding, dietary diversity ,iron rich foods are associated with reduced wasting and stunting in children till 24 months in low income countries 10. In our study, time of introduction of solid food, food diversity and food frequency are associated with malnutrition in children 12-36 months (p=0.000) however early initiation of breastfeeding, breastfeeding at 1 year, were not statistically associated with wasting and stunting. Reasons could be that in our set up, breastfeeding could not be started within one hour after caesarean sections due to pain and other practical problems so , early breastfeeding for the study is kept as six hours.

WHO guidelines for food consistency recommend slowing increment in the food consistency as the infant gets older, adjusting to infants needs and efficiency in chewing. Infants can eat pureed or mashed food beginning at 6 months, by eight months infants can have finger foods or lumpy foods and by 12 months they can have family food as consumed by rest of family 11. Evidence from several sources indicates many children are still offered pureed food by 12 months (presumably because the caregiver believes that the child eats more and it is less time-consuming), there is a suggestive evidence of a crucial window period for introducing lumpy food, if these are delayed beyond ten months, it can lead to feeding difficulties later on 18. The European society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) committee on nutrition emphasized that there may be a critical window for introducing solid foods before the age of 10 months 19. Its recently updated recommendations are widely developed: foods should be of an appropriate texture and consistency for the infant's developmental stage, ensuring timely progression to finger foods and self-feeding. Prolonged use of pureed foods should be discouraged, and infants should be eating lumpy foods by 8–10 months at the latest.

In our study, 45.3% of the mothers changed the texture of food from pureed to lumpy food by 8-10 months. 31.3% changed it in 10-12 months and 23.4 % were given pureed food even after 12 months. Delayed introduction of lumpy food was associated with speech delay (p=0.000). Various authors in the literature have concluded that different food textures progressively augment the maturation of the maxilla and the dento-alvéolar framework 20. Chewing function and constant pressure on the growth process will be inadequate in children who are given pureed food beyond 12 months. Paucity of the development of dental arches which includes central and lateral incisors lead to atrophied maxilla 21. Absence of natural grinding of primary teeth and the atrophied maxilla will result in poorly developed mastication. The soft tissues and the mandible, which are required to perform the efficient masticatory function during administration of most solid consistency food, are basically the same structures that will modify the sound originated from the larynx by variations of the oral cavity spaces, produced by the speech. Failures in the biomechanics of this mechanism can affect the production of specific phonemes 22^.

Numerous publications have reported the key role of the introduction of particular food textures and its relation to acquiring oral skills development during the first years of life especially between 6 and 12 months 8. Speaking function that is enunciation require correct development of praxis which will be followed by complementary feeding recommendations (including food texture introduction) 23.

In our study 64.6% of parents were following screen time recommendation according to WHO recommendations with their children but remaining children (35.3%) who had screen time more than 1 hour per day, were not statistically significantly associated with speech delay (p 0.490) as published in previous studies 24. 12.5% of the children had a positive family history of speech delay, however it is not also statistically significant with speech delay (p 0.835) as suggested by US Preventive task force recommendation that positive family history of speech delay is a strong risk factor for speech delay in children 25.

While evaluating reasons for not giving exclusive breastfeeding till 6 months, majority (91.3%) of mothers stated the belief that breast milk was not enough for the baby, and they have to top up with infant formula or cow milk. Reasons for not starting complimentary feeding by 6 months was lack of information in 60% of mothers. Three mothers reported that baby was not ready to take semi-solid food even if they tried to compliment them. And one mother reported illness of the baby at 6 months for not starting complimentary feeding.

While asking for reasons for not changing texture of food from pureed to lumpy food, 48.2 % mothers expressed fear of choking, 34.4% mothers were unaware about this and were not educated by primary care givers or paediatricians and 5 mothers felt that its not required to change texture as it is less time-consuming to give pureed food.

Single centric observational study with small sample size is the limitation of the study however, counselling of mothers regarding complimentary feeding in terms of time of introduction of complimentary food, food diversity ,food frequency , food texture is recommended to prevent malnutrition and speech delay in 12-36 month old children in Northern Haryana

Given the fact that maternal education and poverty are two socio demographic variables and time of introduction of complimentary feeding, food diversity and food frequency of complimentary feeding impacts nutritional status of children between 12-36 months. Lack of change of texture of complimentary feeding from pureed to lumpy food by 10 months will lead to speech delay in children of 12-36 months.

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