Importance of Breastfeeding for Importance of Breastfeeding for Child Survival , Development and Child Survival , Development and

HealthHealth

Regional Consultation Meet on Nutrition Bhubhneshwar

18-19 July 2005

Dr.Arun Gupta MD FIAPNational coordinator BPNI BP-33, Pitampura, Delhi 110 088arun@ibfan-asiapacific.org

Diarrhoea

Neonatal disordersUnknown

Pneumonia

MeaslesMalaria

Other AIDS Neonatal sepsis

Diarrhoea

Pneumonia

Source: Robert et al. LANCET 2003;361:2226-34

Three Major Killers in India

Neonatal sepsis Breastfeeding is the No. 1 preventive

intervention compared to any other intervention

Lancet Series on child survival, and now on newborn survival : 2003 and 2004

Definition of Breastfeeding : Exclusive breastfeeding for the first six months and continued breastfeeding for next six months

Diarrhea Breastfeeding is the No. 1 preventive

intervention compared to any other intervention

Lancet Series on child survival, and now on newborn survival : 2003 and 2004

Definition of Breastfeeding : Exclusive breastfeeding for the first six months and continued breastfeeding for next six months

Pneumonia Breastfeeding is the No. 1 preventive

intervention compared to any other intervention

Lancet Series on child survival, and now on newborn survival : 2003 and 2004

Definition of Breastfeeding : Exclusive breastfeeding for the first six months and continued breastfeeding for next six months

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Breastfeeding

Complementary feeding

Clean delivery

Hib vaccine

Clean water, sanitation, hygiene

Zinc

Vitamin A

Antenatal steroids

Newborn temperature management

Tetanus toxoid

Antibiotics for PRM

Measles vaccine

Nivirapine and replacement feeding

Insecticide-treated materials

Antimalarial IPT in pregnancy

Inte

rve

ntio

nPercent

Under-5 deaths preventable through universal coverage with individual interventions

Look at other interventions

Source: Jones et al. LANCET 2003;362:65-71

10th Five year Plan

GOALS

9.515.8

5155.2

31.4 33.5

0

20

40

60

80

100

Initiation ofbreastfeeding within 1

hour

Exclusivebreastfeeding (0-3

months)

Complementaryfeeding (6-9 months)

NFHS-1 NFHS-2

Trends in Infant Feeding Practices1992 1999(NFHS-1) (NFHS-2)

Exclusive breastfeeding falls rapidly from first month onwards (NFHS-2-1999)

Exclusive Breastfeeding

72%

61%54.2%

43.3%37%

25.3%19.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1 2 3 4 5 6

Age in Months

Perc

en

tag

es

Target line

Achieved

The deficit to

Make up!

0%

20%

40%

60%

80%

100%

Exclusive Breastfeeding (0-6months)

Continued breastfeeding (6-11months)

It enhances brain development Brain develops in first two years the most Breastfeeding contributes to IQ, visual

acuity, mathematical abilities and analytical capacity. ( evidence available)

Prepares children for BETTER LEARNING at PSE/Schools

What ever level of survival we achieve, we will always achieve higher level of child development: sustainable human development

Exclusive breastfeeding Prevents HIV in infants

Cumulative % with HIV infection acording to early breastfeeding pattern

1.31

3.03

4.4

6.94

8.56

13.92

0

2

4

6

8

10

12

14

16

Exclusive Predominant Mixed

6 months

18 months

Early Exclusive Breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005 19:699-708

It prevents Obesity

Sufficient evidence available that BREASTFEEDING/ExBF prevents childhood obesity

15% urban populations are projected to be obese

American Academy of Pediatrics guidelines: rate Breastfeeding as number one preventive intervention along with decreased TV viewing

Treatment costs are horrible and unaffordable even by USA

It has Huge economic value

Market Value of breastmilk : difficult to put a cost ! Artificial feeding you have to spend about RRs 450 per

day to feed a 3 months old infant, perpetuates income poverty by additional spending on milk and sickness

In the Milk banks of Norway it is available at 50 $ per liter as compared to the cost of powder milk formula of about 2-3 $ per day.

At Current level of production of breastmilk in India : 4000 million liters

If we achieve national goals : 6500 million liters Economic worth $ 326 billion

10th Five Year Plan Goals

Exclusive Breastfeeding 0-6 months

55.2 5848.8

70.7

84.1

NA

80

0

10

20

30

40

50

60

70

80

90

Bihar Jharkhand Orissa West Bengal

NFHS-2 10 Plan Goals

Note: NFHS 2 data for exclusive breastfeeding 0-3 months and 10th Plan Goals data is 0-6 months

Exclusive Breastfeeding 4 states (BPNI Data 2003)

28.6

54.646.1

27.7

0

10

20

30

40

50

60

Bihar Jharkhand Orissa West Bengal

When malnutrition strikes…Under three

11.9

2

37.5

11.8

58.5

23.1

58.4

24.1

0

10

20

30

40

50

60

<6 months 6-11 months 12-23 months 24-35 months

%-2SD %-3SD

NFHS-2, 1998-99First three years are for ever…..

(IMR and Underweight U-3)

6270

96

5154.4 54.4 55.448.7

0

20

40

60

80

100

120

Bihar Jharkhand Orissa West Bengal

IMR Under-weight children

IMR (MOHFW, 2001)

Under-weight children (NFHS-2)

Exclusive breastfeeding prevents child malnutrition Strikes Where it begins in early

child hood 0-6 months is critical, 6-12 is next We allow child undernutrition to set in With poor feeding( BREASTFEEDING and

COMPLEMENTARY FEEDING ) Neonatal infections, Diarrhea, pneumonia, 2/3

mortality is in 1st year According to WHO, 2/3rd mortality is related to

poor feeding practices

Can we save babies? YES Make IYCF widely available Prevent malnutrition in children

What works ?Behavior change and timing is critical Intervention must be as close to

desired change Requires Skillful acts not as we

deliver a vaccine

Experience from Bihar villages 20-80% mothers in rural area start some supplements

within first 2 months. Most mothers do so because they feel “not enough

milk” None of the ANMs in PHC could provide correct

answer to what should be done, neither an AWW ( one of whom was MSc Home Science)

HWs and RMPs provide “top milk feeds as advice” Commercial promotion makes formula and bottle use

as common

Summary findings of a qualitative study from 49 districts(98 blocks) BPNI, India 2003 Inadequate knowledge in the community as well as in

the healthcare system. Lack of access to skilled counsellingskilled counselling and practical

support by health care workers Traditional practices. Lead to pre-lacteal feeding Separation of mother and baby immediately after

delivery continues. (in private sector) Families and mothers believe that mothers don’t have

enough milk. Long working hours in offices and in the field Confusing/conflicting messages by health functionaries

What ICDS offers? Women workers : AWWs and helpers Context is “food” for poor or

malnourished, SNP and PSE as core interventions Food based interventions tackling

“HUNGER” And for the younger ones it is not an issue

What is left out ? Lack of understanding what are

determinants of child malnutrition For the 0-6 months it is Exclusive breastfeeding

and 7-24 months continued BREASTFEEDING with adequate complementary feeding

ICDS’s position as true child development programme

Nutrition and health education : weakest and IYCF is missing; skills on IYCF counseling for motivation of mothers are non existent .

REPOSITION ICDS

Outcome should be “Smart kids”Healthy kidsSmiling kids Smart ADULTS Smart SOCIETY

What makes women successful in BF

Practical help and support from all quarters especially health care providers. •Good accurate information and timely counseling•Building confidence when they have a ‘feeling’ of not enough milk, •Assistance

•To initiate breastfeeding within one hour, •Assistance in proper sucking position to allow effective and frequent sucking and thus optimal milk transfer;•Prevent breast problems like sore nipples and engorgement, •Solve problems if they do arise, •Answer any questions if mothers may have,

•Counseling on adequate and appropriate complementary feeding, •Counseling on HIV and Breastfeeding for infant feeding options and support to their choice.

ACTION:Make breastfeeding support visible more widely available

Making breastmilk more widely available Mother support networks Breastfeeding support centers;(this is not

another building) Successful women offering help Redefine the role of workers specifically

holding AW responsible for under three nutrition and IYCF counseling as service in DWCD organogram

Integrate IYCF effectively In outreach programmesWhat does that mean? Strengthening of Pre-service 7 days training on Breastfeeding, complementary

feeding, and HIV for ALL health professionals 3- days training for frontline workers (We have done this for NACO recently) putting

infant feeing in the counselors training, other departments also needed to do similar exercise)

In service : Additional skills training is necessary

Put effective monitoring in place Exclusive breastfeeding 0-6 months

as lead proxy indicator of progress With its allocations With a Context With an accountability mechanism REPORT it annually

What health systems offers?

So far relied on pieces of occasional information not on education which requires skills

Inadequately equipped with skills Less supportive of breastfeeding HWs and doctors believe they know enough Encourage adoption of artificial feeding for

no fault of women

What Health should do? Implement the “Investing in Development” A

Practical Plan to Achieve the MDGs: Report to the UN Secretary General Millennium Project NY 2005” and offer

1. “Neonatal Integrated Package” that includes, breastfeeding education including for HIV positive mothers.

2. Provide continuing education services to ICDS3. Cant wait for IMNCI to be available universally4. Newborn care and BREASTFEEDING must be

universalized now

Preparation of trainers (learning training skills 1wk)

Training of trainers FLW 1wk

Training of FLW 3days

Trainer + Co-trainer

Director

I& Y C F Counseling: A Training CourseThe 3 in 1 course

Learning through conducting training using module 1wk

Course- Structure (Algorithm)

SKILLS

Can we do all this without costs?

This is what is we need to do differently Reorganize resources for Care under one

including maternal nutrition and care 10th Plan notes that improving infant feeding

does not require additional spending. This thinking needs to change!

Ensuring this Free fluid costs! Not delivered as vaccines but does much more

than that Requires as much spending

What other states are doing in collaboration with BPNI?

UP: training of ALL frontline workers in 8 districts ( Sitapur has begun)

Uttranchal : 13 district study on INFANT AND YOUNG CHILD FEEDING and FU with a state plan in one year.

Haryana : In its State allocation, budgeted on improving infant and young child feeding and got it

Training initiatives started in MP, Bihar, Rajasthan (Govt-BPNI-UNICEF)

Pondicherry, AP, Punjab: Initial enquiries with us

INVEST WISELY ! Put budget lines for IYCF action

plans with annual monitoring in relation to development

At least match with vaccination programmes

11th plan is at arms length !

Reorganize resources, each step requires allocation

Prenatal- 0-6

months6 m-3 yrs 3 -6 yrs.

CARE : Skills training

and

Counseling, care of women

HEALTH

Immunization etc

FOOD SUUPLY

for

Hunger/ PSE

National guidelines on IYCF launched 6 August, 2004

The law to protect, promote and support breastfeeding: 6 August,2004

Beginning of the rise of breastfeeding !Be a part of history !!

Thanks !