Promoting healthy growth and survival in young children in their early years requires appropriate complementary feeding practices. In sub-Saharan Africa (SSA), 6% to 41% of under-5 deaths could be prevented by improving these practices [1]. The period from conception to 2 years is particularly critical: inadequate nutrition leads to an increased risk of mortality, stunting, and developmental deficits. Initiation of breastfeeding within one hour of birth, exclusive breastfeeding for the first six months, as well as dietary diversification adapted to the appropriate time, are essential to ensure optimal and healthy growth and development in young children [2]. Complementary feeding practices in West Africa remain inadequate, contributing to stunting, undernutrition, morbidity, and child mortality in the region. Stunting rates among children under 5 years of age range from 19.6% in Senegal to 54.8% in Niger, reflecting inadequate complementary feeding among children in these countries [1]. Overall, less than a quarter of children aged 6 to 23 months meet the minimum standards for dietary diversity and frequency set by WHO. As a result, 32% of children are stunted, and 10% are wasting. Many determinants influence feeding practices: the age of the child, the mother’s level of education and occupation, household wealth, family size, exposure to the media, antenatal care, and delivery conditions [3]. To address this, several global initiatives have been launched, including the UN’s Zero Hunger Challenge and the WHO’s strategies to promote adequate complementary feeding. Despite these efforts, gaps persist. Therefore, identifying and reducing preventable socioeconomic inequalities related to the minimum acceptable dietary intake and its contributing factors is a key priority to improving children’s overall health and well-being [4]. The DRC is struggling to recover after years of conflict and political crises, while facing serious humanitarian challenges. Since 2017, ongoing instability in the east of the country has displaced an estimated 4.8 million people, depriving them of their livelihoods. Food insecurity has worsened sharply, from 7.7 million people affected in 2017 to 13.1 million in 2018, making access to food a daily challenge for a large part of the population [5]. Nearly 42% of children under 5 years of age are stunted, 6% are wasted, 23% are underweight, and 47% are anemic. Only 18% and 37% of children aged 6 to 23 months achieve the minimum dietary diversity and recommended frequency, respectively [6]. The DRC remains one of the countries most affected by chronic and acute malnutrition [7]. Although various factors contribute to malnutrition, inadequate dietary practices remain among the most important [8]. In Ituri province, few studies have looked at feeding practices among children aged 6 to 23 months. Understanding their influence on nutritional status is essential, as inadequate complementary feeding permanently compromises the growth and development of the child.

The general objective of this study is to analyze the influence of dietary practices and the sociodemographic characteristics of the mother and child on the nutritional status of children aged 6 to 23 months in the Komanda Health Zone.

The results of the anthropometric assessment carried out in the Komanda Health Zone highlight a worrying situation in terms of child malnutrition. Indeed, 50.7% of children are stunted, 25.1% are underweight, and 15.8% are wasting. These levels remain high compared to the profiles described in the literature in East Africa and sub-Saharan Africa [8][9]. Our study highlights the particular concern of stunting, as it impacts not only children’s physical but also cognitive development, with long-term consequences for their future health and productivity. Factors associated with stunting include poverty, food insecurity, low maternal education, low household wealth, rural residence, and large family size [9]. In addition, underweight and wasting are critical indicators of acute malnutrition. A hierarchical analysis conducted in several low- and middle-income African countries estimated the prevalence of underweight at 17.6% and identified several associated factors, including child sex, maternal characteristics, and socioeconomic background [10]. A recent review also highlighted the varying extent of wasting in sub-Saharan Africa across contexts [9]. In terms of dietary practices, the majority of children in our study started complementary feeding at 6 months of age, in line with WHO recommendations. However, multi-country analyses in sub-Saharan Africa show that the overall practice of appropriate complementary feeding remains low, a reminder that compliance with the age of introduction alone does not guarantee adequate feeding. In our series, 60% of children consumed at least four food groups. However, analyses in East Africa show that the proportion of children achieving a minimum acceptable diet remains low in several contexts [11]. Regarding the number of meals, 61.89% of the children ate two meals a day, suggesting that a significant proportion of the children did not reach the minimum recommended frequency. An analysis in sub-Saharan Africa estimated the prevalence of minimum meal frequency at 38.47%, confirming the persistence of a food frequency deficit in the region [12]. Also, snacks were infrequent in our series.

Combining the criteria of dietary diversity and minimum frequency of meals, 49.68% of children have a minimum acceptable diet. Our findings far surpass the results of a study conducted in East Africa, which reported that only 11.56% of children met these criteria, highlighting the persistent challenges in ensuring adequate nutrition [11].

The influence of child sex on malnutrition is reported in several African analyses, where the male sex appears to be more often associated with underweight and stunting [8]. Our results point in the same direction in bivariate analysis, and the protective effect of female sex persists for underweight in multivariate analysis.

The age of the child deserves a careful reading. In our bivariate analysis, the age medians of underweight and wasted children were lower. In contrast, after adjustment, child age was positively associated with underweight and wasting. Studies in sub-Saharan Africa have also shown that the risk of malnutrition varies across age groups, particularly in the second half of life and the 12 - 23-month period [13].

The association between maternal education and stunting observed in bivariate analysis is consistent with the literature. Research from the DRC and East Africa shows that low maternal education is linked to a higher risk of chronic malnutrition in children [8]. This study identified several dietary practices related to nutritional outcomes, including dietary diversity, meal frequency, consumption of certain food groups, minimum acceptable diet adherence, and snack frequency. A study conducted in Tanzania showed that dietary diversity is associated with the nutritional status of children aged 6 to 23 months [14]. In addition, a review conducted in sub-Saharan Africa found an association between dietary diversity and undernutrition in children aged 6 to 23 months [15].

In our series, a higher minimum frequency of meals was associated with a lower likelihood of being underweight. This result is consistent with multi-country data from sub-Saharan Africa on minimum meal frequency [12] as well as the study conducted in Malawi on appropriate complementary feeding practices [16]. Data on foods of animal origin point in the same direction, and a study in Cambodia showed that the consumption of foods of animal origin and dietary diversity contribute to reducing stunting [17].

A Minimum Acceptable Diet summarizes the overall quality of the complementary diet better than each indicator taken in isolation. In our study, it appears to be protective against underweight and wasting. Multi-country analyses in sub-Saharan Africa have also shown that better adherence to the minimum acceptable diet is associated with better nutritional outcomes in children aged 6 to 23 months [11].

Dietary diversity remains a central lever. In our model, insufficient dietary diversity was associated with wasting. This finding is consistent with the work available in India and sub-Saharan Africa, which shows that a more diversified diet is linked to better growth parameters [1][14].

Our results on meal frequency also support the interest of interventions focused on infant and young child feeding. Children who received meals more frequently had lower odds of being underweight than those who did not receive a minimum meal frequency. This observation reinforces the importance of IYCF messages on both quantity and regularity of food intake [12].

In contrast, no factors were associated with stunting in the adjusted model. This lack of a significant association can be explained by the multifactorial nature of stunting, which incorporates nutritional, infectious, environmental, and socioeconomic influences over time [14].

The analysis indicates that for underweight, female sex and a minimum acceptable diet serve as protective factors, while increasing child age correlates with higher odds. Regarding wasting, older age and insufficient dietary diversity increase the likelihood, while a minimum acceptable diet remains protective. These findings are consistent with data presented in Table 4.

These results are in line with the regional literature, which reports a variability of associations according to the nutritional indicators studied and according to the level of statistical adjustment used [8][10][11]. Despite these nuances, our evidence supports the need for targeted interventions to improve the quality and consistency of complementary feeding during the 6 - 23-month window [12].

This study has several limitations. First, its cross-cutting design does not allow for the establishment of a causal relationship between dietary practices and nutritional outcomes. Second, the food variables relied on maternal recall, which exposes them to memory bias and social desirability risk. Third, the survey covered only 10 out of 17 health areas due to insecurity, which limits the generalization of the results to the entire Komanda Health Zone. Finally, the lack of adjustment of standard errors for the cluster effect requires a cautious interpretation of the regression estimates.

The results of this study show a high incidence of stunting, underweight, and wasting among children aged 6 to 23 months in the Komanda Health Zone. A Minimum Acceptable Diet was found to be an important protective factor against underweight and wasting, while insufficient dietary diversity and advancing age were associated with wasting. For underweight, female sex was protective, and a higher minimum frequency of meals was associated with better outcomes. These results argue for strengthening IYCF interventions focused on the quality and regularity of complementary feeding.

D.N.G. conceptualized the study and prepared the manuscript. R.I.B. performed the data analysis. J.L.L. supervised the manuscript writing. All authors contributed to the study design, data collection, critical revision of the manuscript, and approved the final version of the manuscript.