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Nigeria has African’s largest population of more than 180 million, including 40 million children, and is the largest recipient of developmental assistance for health in Africa. Despite a range of policy initiatives to improve infant and young child feeding (IYCF) practices in Nigeria, an estimated 2,300 children under–5 years lose their lives daily, in which sub-optimal IYCF practices play a major role. Inappropriate IYCF practices also contribute substantially to lost productivity among children under–5 years in Nigeria, accounting for more than 40,000 disability–adjusted life years. A series of studies were conducted in this thesis to investigate: 1. the socio-economic status and health service factors associated with sub-optimal breastfeeding practices in Nigeria using the Nigeria Demographic and Health Survey (NDHS); 2. trends and differentials in key breastfeeding indicators in Nigeria using the NDHS data; 3. the secular trends and determinants of changes in complementary feeding indicators in Nigeria using the NDHS data; 4. the association between infant and young child feeding practices and diarrhoea in Nigeria using pooled NDHS data; 5. time-trends in infant and young child feeding practices in Nigeria in the context of the implementation key national policy responses and initiatives; and 6. to quantify and compare the attributable and avoidable burden of non-EBF associated with key modifiable risk factors in the Nigeria. In Nigeria, no nationally representative study has investigated the social and health service determinants associated with sub-optimal breastfeeding practices. Associations between socio-xiii economic position and health service contacts of mothers and key sub-optimal breastfeeding practices (that is, early initiation of breastfeeding, exclusive breastfeeding, predominant breastfeeding and bottle feeding) were investigated to inform health interventions and policies at the national level in Nigeria (Chapter 3). This national study found that key breastfeeding practices (that is, early initiation of breastfeeding, exclusive breastfeeding, predominant breastfeeding and bottle feeding) were below expected levels in Nigeria. The analyses found that early initiation of breastfeeding was associated with mothers from higher socio-economic status, mothers who had frequent health service contacts and those whose birth interval was greater than or equal to 24 months. Exclusive breastfeeding was associated with higher socio-economic status, younger maternal age and geopolitical region. Predominant breastfeeding was associated with lower socio-economic status and fewer contacts with health services, while bottle feeding was associated with higher socio-economic status, caesarean delivery, four or more antenatal visits and younger child age (0-12 months). Nigeria is a developing country undergoing significant socio-economic and political changes with subsequent impact on familial and gender role differentiation, including social mobility of women. Given the socio-economic and political transition in the Nigerian context, the next national study (Chapter 4) investigated changes in key breastfeeding indicators (early initiation of breastfeeding, exclusive breastfeeding, predominant breastfeeding and bottle feeding) by socio-economic factors, health service factors and individual characteristics using Nigeria Demographic and Health Survey (NDHS) data over a period spanning (1999–2013). The nationally representative study found an increasing trend in the prevalence of educated mothers who exclusively and predominantly breastfeed their babies compared to mothers with no schooling. A similar increasing trend was evident for mothers from wealthier households xiv and mothers who had a higher frequency of health service access compared to mothers from poorer households and women who reported no health service access, respectively. Malnutrition is a major issue of public health importance in Nigeria. Inappropriate complementary feeding practices among mothers have been reported as playing a major role in the prevalence of malnutrition in other developing contexts. To the candidate’s knowledge, this is the first population-level study in Nigeria (Chapter 5) to provide an exposition of trends in complementary feeding indicators, that is, the introduction of solid, semi-solid or soft foods, minimum dietary diversity, minimum meal frequency and minimum acceptable diet for the period (2003–2013), and to examine whether these trends differ by socio-economic, health service and individual characteristics. This national study found that minimum dietary diversity and minimum acceptable diet for children aged 6–23 months worsened, while minimum meal frequency improved over the study period (2003-2013). Among educated mothers, there was a decreasing prevalence of the introduction of solid, semi-solid and soft foods for infants aged 6–8 months; minimum dietary diversity and minimum acceptable diet for children aged 6–23 months. The prevalence of mothers who met the minimum dietary diversity worsened significantly over time among mothers, regardless of household wealth status. A similar worsening trend was identified in mothers irrespective of mother’s age and frequency of antenatal clinic visits. Mothers with a higher education attainment and those who reported more health service contacts were more likely to meet the minimum dietary diversity. Globally, Nigeria has the largest proportion of children who suffer from diarrhoea-related morbidity and mortality each year. Appropriate and safe IYCF practices have been well-documented to protect children against diarrhoea-related morbidity and mortality in many developing contexts; however, the impact of optimal IYCF practices on diarrhoea has not been xv studied in Nigeria to provide up-to-date and context-specific evidence. To the candidate’s knowledge, Chapter 6 is the first nationally representative study in Nigeria to report on the relationship between key breastfeeding practices and diarrhoea among Nigerian children. This Chapter also provides important information on the relationship of diarrhoea with other broader IYCF indicators (such as continued breast feeding at one year and introduction of solid, semi-solid, and soft foods) and the potentially modifying role of water and sanitation in Nigerian communities. This national study found that the prevalence of diarrhoea was higher among children whose mothers did not initiate breastfeeding feeding within the first hour of birth, infants who were not exclusively breastfed, and infants who were prematurely introduced to complementary foods (including infant formula). Early initiation of breast feeding was significantly associated with lower risk of diarrhoea. Exclusively breastfed infants were less likely to develop diarrhoea compared to non-exclusively breastfed infants. Predominant breast feeding was significantly associated with a lower risk of diarrhoea. Bottle feeding and introduction of complementary foods were associated with a higher risk of diarrhoea. The protective effect of EIBF against diarrhoea was stronger among mothers who had improved sanitation, while the protective effect of EBF against diarrhoea was stronger among mothers who used an unimproved type of toilet. Evidence from Chapter three to five found that the proportion of mothers who practice optimal IYCF practices in Nigeria is low compared to global recommendation. This low prevalence was observed despite a range of national and sub-national initiatives introduced in Nigeria to promote, protect and support optimal IYCF practices. To the candidate’s knowledge, Chapter 7 is the first study to presents the results of a data analysis that investigate time trends in IYCF practices in Nigeria for the period (1999-2013), spanning the development and implementation of a range of key national and sub-national policy responses and initiatives to improve IYCF xvi practices in Nigeria. This chapter provides a narrative overview of these policy responses and initiatives, and describes the need for context-specific maternal and child health policy reforms and funding in Nigeria to protect, promote and support optimal IYCF practices. The national study showed that early initiation of breastfeeding decreased significantly by 4.3% over the period (1999-2013), while exclusive breastfeeding remained unchanged. From 2003 to 2013, minimum meal frequency increased significantly by 13.8%, but minimum dietary diversity and minimum acceptable diet decreased significantly by 9.7% and 3.5%, respectively. Predominant breastfeeding increased significantly by 13.1%, and children ever breastfed declined by 16.4% over time. Previous reports (including those from this thesis) have revealed that non-exclusive breastfeeding (non-EBF) is a risk factor for a number of diseases, including diarrhoea and upper respiratory infections. To the candidate’s knowledge, Chapter 8 is the first report of a Nigerian study to provide attributable and avoidable burden estimates of key modifiable risk factors associated with non-EBF to inform strategic initiatives and policy responses. The study found that an estimated 22.8% of non-EBF was attributable to poor maternal education in Nigeria; 24.7% to poor household wealth; 9.7% to no antenatal care visits; 18.8% to home delivery; and 16.6% to delivery assisted by a non-health professional. In combination, more than half of all cases of non-EBF (64.5%) could be attributable to these modifiable risk factors. Scenarios based on feasible impacts of community-based approaches to improve health service access and capacity suggest that an avoidable burden of non-EBF practice of approximately 11% is achievable. xvii Evidence from these studies highlights the need for a comprehensive strategic plan that is measureable, context-specific and cost-effective to improve IYCF practices in Nigeria, and to build on previous policy initiatives of the past decades. Furthermore, the involvement of relevant government agencies, non-governmental organisations, and health workers at all levels, including community stakeholders is also important to reduce sub-optimal feeding practices and subsequent preventable under-5 deaths in Nigeria. The effective use of available resources, better accountability and monitoring of health fund expenditure is also vital to improving IYCF practices in Nigeria.