Introduction
The early years of life are the most critical stage in the growth and development of children. While the optimal development of children depends on a complex set of factors, the pattern of breastfeeding and complementary feeding of infants is of undeniable importance. 
Although the pattern of complementary feeding of infants is affected by each region’s social, cultural, and economic conditions, the level of mother awareness and the ability to access food play a role in determining this pattern. Moreover, some studies have shown that increasing the mothers’ attitudes and knowledge plays a key role in the process of their performance regarding the proper nutrition of children [16,17]. UNICEF studies show that about 39% of babies under six months are exclusively breastfed. Therefore, the main purpose of the present study was to investigate the factors related to the feeding patterns of one-year-old children who were referred to healthcare centers in Rafsanjan.

Materials and Methods
This descriptive study was performed on 600 mothers with one-year-old children under the auspices of healthcare centers in Rafsanjan in 2017. Volunteered mothers with active health records were selected randomly. 
To determine the sample size, the formula n=(Z2 PQ)⁄ d2 was used, in which the ratio of exclusive feeding in children (p) according to the study of Khabaz Khob et al. [20] in Mashhad is equal to 0.56 and the accuracy of estimation (d) was considered equal to 4% and finally, the sample size for conducting this study was calculated to be 600 people. Stratified random sampling was used and some samples were randomly selected from each health center considered as a stratum, according to the size of that center. In nine urban health centers, the names of all 12-month-old children were listed, and then 300 people were randomly sampled. Then, among 82 rural health centers,  20 health centers were selected according to factors, such as the density of the covered population and the location of the center (north, south, east, and west of Rafsanjan), and then 300 people were selected randomly. Children who had congenital diseases, including cardiac, pulmonary, respiratory, and digestive diseases were excluded from the sample.
Because the highest ratio in observing the nutritional patterns (50%) is about 386 samples, the researchers increased the sample size to 600 children to increase the accuracy of the present study. The required information was collected through a questionnaire containing demographic characteristics and questions related to the feeding of children and analyzed by SPSS software, version 18. Descriptive statistics, including frequency and percentage and mean and analytical statistics were performed using Chi-square and Fisher’s exact tests. The significance level in all tests was considered equal to 0.05.

Results
About 95% of mothers participating in this study started breastfeeding their children up to one hour after delivery, but 56.7% of them completed breastfeeding by one year of age. The results show that most mothers had started supplemental feeding with two or three spoons in each meal, and about 90% of them followed the health worker›s advice. Also, the most important reasons for feeding children with powdered milk were disorders in the child’s development (34%), inadequate breast milk (17%), maternal disease (14%), not taking the mother’s breast (11%) and children being twins (8%).
According to the findings of this study, the reasons for the rest of the mothers to stop breastfeeding before one year of age included the lack of milk (55%), rejection of the mother’s breast by the child (21%), simultaneous pregnancy (8%), working mother, separation of parents, and the illness of the mother or the child. The rate of exclusive feeding with breast milk was 51.7%. In children who were not exclusively fed with breast milk, complementary foods (45%), powdered milk (45%), and water (sugar water, boiled candy water, ...) were the most food items. About 58% of mothers had previous breastfeeding experience. Among the mothers with previous breastfeeding experience, this experience was successful in about 91% of them.
Among the qualitative variables, based on the Chi-square test, there was only a significant relationship between mothers’ breastfeeding for up to 12 months with successful breastfeeding experience and mothers’ desired pregnancy. The main point is that 75.2% of mothers had breastfeeding training during pregnancy. Also, 70% of the studied mothers had received breastfeeding training through the staff and educational brochures of health centers, and the rest of the mothers had received this training from hospitals, people around them, and mass media.

Discussion 
Despite the emphasis of the World Health Organization and UNICEF on exclusive breastfeeding until six months, the result of the present study showed that only 52% of mothers in Rafsanjan follow this scientific recommendation. Moreover, the results of our study showed that exclusive breastfeeding in children less than six months of age in Rafsanjan city was higher than the global average values ​​(34%) reported by UNICEF [5]. This is while the results of the previous study conducted by Ansari Jabri et al. indicated that the rate of exclusive breastfeeding in children less than six months in Rafsanjan city was nearly 70% [21].
Although it is difficult to determine the cause of the difference observed in these two studies due to the difference in the type of quantitative and qualitative indicators investigated, it seems that the type of sampling has a main effect on the results of the two studies. Because the samples selected in the previous studies only included 412 urban women referring to seven health centers in Rafsanjan. Meanwhile, in this study, in addition to 300 samples selected from nine urban health centers, 300 samples were also selected from 20 health centers in Rafsanjan. Further, the results of studies in other regions of Iran show that the rate of exclusive breastfeeding in children under six months in Shiraz, Jahrom, Bandar Abbas, Kashan, and Tehran is 61, 55.4, 55.4, 33, and 35.2 [22-26].
Despite face-to-face training for mothers in healthcare centers for feeding their children, still, there are some difficulties in commencing complementary feeding and its continuation. Therefore, there is a need for more health and nutrition education for mothers regarding the best ways to feed children by the personnel of Rafsanjan healthcare centers.

Ethical Considerations

Compliance with ethical guidelines
The Ethics Committee of Rafsanjan University of Medical Sciences (RUMS) approved the present study (Code: IR.RUMS.REC.1396.179). Participants were allowed to withdraw at any time. Moreover, all participants were aware of the research process. 

Funding
This study was funded by the Rafsanjan University of Medical Sciences (Grant No.: 96156). 

Authors' contributions
Conceptualization, editing, and writing of the main draft: Seyed Zia Tabatabaei; Methodology and data collection: Farzaneh Hajizadeh, and data analysis: Fatemeh Ebrahim

Conflicts of interest
None declared.
The authors declare that they have no conflict of interest. 

Acknowledgements
We wish to thank all participants, especially mothers and healthcare staff for their participation and corporation. 

 

1. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012. [DOI:10.1002/14651858.CD003517.pub2]
2. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: A systematic review and meta-analysis. Acta Paediatr. 2015; 104(S467):96-113. [DOI:10.1111/apa.13102] 
3. Lassi ZS, Rind F, Irfan O, Hadi R, Das JK, Bhutta ZA. Impact of infant and young child feeding (iycf) nutrition interventions on breastfeeding practices, growth and mortality in low-and middle-income countries: Systematic review. Nutrients. 2020; 12(3):722. [DOI:10.3390/nu12030722] [PMID] [PMCID]
4. Daelmans B, Dewey K, Arimond M. New and updated indicators for assessing infant and young child feeding. Food Nutr Bull. 2009; 30(2-S 2):S256-62. [DOI:10.1177/15648265090302S210] [PMID]
5. Unicef. Key facts and figures on nutrition. New York: Unicef; 2013. 
6. Unicef, World Health Organization. Tracking progress for breastfeeding policies and programmes. Geneva: World Health Organization; 2017. [Link]
7. Ghaffari V, Vahidshahi K, Parviniejad N, Ghavanch Zade TM. [Assessment of mothers' attitude toward exclusive breast feeding, Sari, 1386 (Persian)]. J Jahrom Univ Med Sci. 2009; 7(1):53-61. [DOI:10.29252/jmj.7.1.2.53]
8. Jalahi H, Mohammad pour R, Gholami S, Vahedi H. [Reasons for formula milk consumption in infants under 6 months in Mazandaran province in 2003 (Persian)]. J Mazandaran Univ Med Sci. 2005; 15(46):111-6. [Link]
9. Ebrahimi S, Poor Mohamadi A. [A study on complementary nutrition and its related factors in Kohkiloyeh and Boirahmad (Persian)]. Armaghane-danesh. 2002; 6(24):8-15. [Link]
10. Prell C, Koletzko B. Breastfeeding and complementary feeding. Dtsch Arztebl Int. 2016; 113(25):435-44. [DOI:10.3238/arztebl.2016.0435] [PMID] [PMCID]
11. White JM, Bégin F, Kumapley R, Murray C, Krasevec J. Complementary feeding practices: Current global and regional estimates. Matern Child Nutr. 2017; 13(S 2):e12505. [DOI:10.1111/mcn.12505] [PMID] [PMCID]
12. Koletzko B, Dodds P, Akerblom H, Ashwell M. Early nutrition and its later consequences: new opportunities: Perinatal programming of adult health- EC supported research.  Berlin: Springer Science & Business Media; 2005. [Link]
13. Alvisi P, Brusa S, Alboresi S, Amarri S, Bottau P, Cavagni G, et al. Recommendations on complementary feeding for healthy, full-term infants. Ital J Pediatr. 2015; 41:36. [DOI:10.1186/s13052-015-0143-5] [PMID] [PMCID]
14. Jofiro G, Jemal K, Beza L, Heye TB. Prevalence and associated factors of pediatric emergency mortality at Tikur Anbessa specialized tertiary hospital: A 5 year retrospective case review study. BMC Pediatr. 2018; 18(1):316. [DOI:10.1186/s12887-018-1287-4] [PMID] [PMCID]
15. Salarkia N, Amini M, Eslami M, Dadkhah M, Zoghi T, Haidari H, et al. Mothers' views and beliefs about the role of complementary feeding in children under the age of two in Damavand: A qualitative study (Persian)]. J Arak Uni Med Sci. 2010; 13(2):63-74. [Link]
16. WHO. Guiding principles for complementary feeding of the breastfed child. Geneva: WHO; 2003. [Link]
17. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475-90. [DOI:10.1016/S0140-6736(15)01024-7] [PMID]
18. Dalili H, Shariat M, Nayeri F, Emami Z, Sahebi R, Sahebi L. Duration of breastfeeding and maternal-related factors in Iran, systematic review and meta-analysis. J Pediatr Nurs. 2020; 54:e23-30. [DOI:10.1016/j.pedn.2020.04.011] [PMID]
19. Behzadifar M, Saki M, Behzadifar M, Mardani M, Yari F, Ebrahimzadeh F, et al. Prevalence of exclusive breastfeeding practice in the first six months of life and its determinants in Iran: A systematic review and meta-analysis. BMC Pediatr. 2019; 19(1):384. [DOI:10.1186/s12887-019-1776-0] [PMID] [PMCID]
20. Khabazkhoob M, Fotouhi A, Majdi M, Moradi A, Javaherforoshzadeh A, Haeri Kermani Z, et al . [Prevalence of exclusive breastfeeding in health center Mashhad, 2007 (Persian)]. Iran J Epidemiol. 2008; 3(3-4):45-53. [Link]
21. AnsariJaberi A, NegahbanBonabi T, Alahtavakoli M, Kazemi M. [Maternal affectivity and their infants feeding pattern among referrers to health care centers in Rafsanjan in 2011 (Persian)]. J Rafsanjan Univ Med Sci. 2015; 14(1):47-56. [Link]
22. Saki A, Eshraghian MR, Tabesh H. Patterns of daily duration and frequency of breastfeeding among exclusively breastfed infants in Shiraz, Iran, a 6-month follow-up study using Bayesian generalized linear mixed models. Global J Health sci. 2013; 5(2):123-33.  [DOI:10.5539/gjhs.v5n2p123] [PMID]
23. Torabi S, Managheb S, Rahmanian S, Zahedi R, Solhjoo Z. [Nutritional status of children under two years and its associated factors in urban and rural areas of Jahrom, 2007-8 (Persian)]. J Jahrom Univ Med Sci. 2011; 9(2):15-20. [DOI:10.29252/jmj.9.2.15]
24. Almasi H, Saberi H, Moraveji SA. [The pattern of exclusive breast feeding in neonates under healthcares in health centers of Kashan city during 2006 (Persian)]. Feyz. 2010 ; 14(2):163-8. [Link]
25. Ghanbarnejad A, Abedini S, Taqipoor L. [Exclusive breastfeeding and its related factors among infants in Bandar Abbas city, Iran (Persian)]. J Babol Univ Med Sci. 2014; 16(1):85-91. [doi:10.18869/acadpub.jbums.16.1.85]
26. Kermani R, Nedaeifard L, Tehrani M, Nateghi MR, Fazeli A. Pattern of breastfeeding in infants conceived by assisted reproductive techniques at royan institute from birth to 6 months in Tehran-Iran. J Fam Reprod Health. 2012; 6(3):105-9. [Link]
27. Olang B, Farivar K, Heidarzadeh A, Strandvik B, Yngve A. Breastfeeding in Iran: Prevalence, duration and current recommendations. Int Breastfeed J. 2009; 4:8. [DOI:10.1186/1746-4358-4-8] [PMID] [PMCID] 
28. Rahmatnejad L, Bastani F. [Factors associated with discotinuation of exclusive breast feeding by first time mothers (Persian)]. Iran J Nurs. 2011; 24(71):42-53. [Link]
29. WHO. Report of the expert consultation of the optimal duration of exclusive breastfeeding, Geneva, Switzerland, 28-30 March 2001. Geneva: World Health Organization; 2001. [Link]
30. Fesharakinia A, Sharifzadeh G, Habibi Mood H. [Evaluation of infants' complementary nutrition pattern and some of its associated factors in Birjand (Persian)]. J Birjand Univ Med Sci. 2009; 16(3):40-6. [Link]
31. Aghababaii S, Artimani T, Mahjoob H, Shobeiri F. Assessing the infant's breastfeeding in Hamadan city Iran. E3 J Med Res. 2015; 4(2):023-7. [Link]
32. Sultan AN, Zuberi RW. Late weaning: The most significant risk factor in the development of iron deficiency anaemia at 1-2 years of age. J Ayub Med Coll Abbottabad. 2003; 15(2):3-7. [PMID]
33. Delaram M. [The effects of passive smoking on pregnancy outcome, Hajar Hospital, Shahrekord (Persian)]. J Shahid Sadoughi Univ Med Sci. 2007; 15(2):39-44. [Link]
34. Sayed N, Schönfeldt HC. A review of complementary feeding practices in South Africa. South Afr J Clin Nutr. 2020; 33(2):36-43. [DOI:10.1080/16070658.2018.1510251]
35. Manikam L, Lingam R, Lever I, Alexander EC, Amadi C, Milner Y, et al. Complementary feeding practices for South Asian young children living in high-income countries: A systematic review. Nutrients. 2018; 10(11):1676. [DOI:10.3390/nu10111676] [PMID] [PMCID]
36. Mirahmadizadeh A, Zare P, Moradi F, Sayadi M, Hesami E, Moghadami M. [Exclusive breast-feeding weaning pattern and its determinant factors in Fars province in 2010 (Persian)]. Daneshvar Med. 2012; 20(2):11-22. [Link]