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Dr. Malik Shahnawaz Ahmed

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` Child is the chief victim of interplay of nutrition, socio-

economic and health factors that cause malnutrition.

` The steep rise in malnutrition in children during the first two

years of life is indicative of poor infant feeding practices

` WHO: 2/3rd of all under five deaths are related to POOR

FEEDING.

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Malnutrition strikes the most in infancy beginning in 3Malnutrition strikes the most in infancy beginning in 3--44thth month , 29month , 29--30 % at 6 months, goes up and peaks30 % at 6 months, goes up and peaksabout 46% by 18 months, flat curve after that (NFHSabout 46% by 18 months, flat curve after that (NFHS3).3).

Years of life

Brain development

Underweight (-2sd) NFHS-3

Over 60 million

10 lakh children

die during

first month,

14 lakhs by

1 year, and 20 lakhs

by 5 yrs. 2/3rd are related to poor feeding.

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Diarrhoea

Neonatal

disordersUnknown

Pneumonia

Measles

Malaria

OtherAIDS Neonatal disorders

Diarrhoea

Pneumonia

Breastfeeding is the No. 1 preventive intervention compared to any other intervention

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1

2

3

4

6

15

4

6

15

0 2 4 6 8 10 12 14 16

Measles vaccine

Vitamin A

Water, sanitation, hygiene

Clean delivery

Complementary Feeding

Breastfeeding

Newborn resuscitation

Antibiotics for pneumonia

Oral rehydration therapy

Percentages

U-5 child deaths (%) saved by universalising

key interventions in India

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� WHO introduced InternationalCode for Protection &

Promotion of Breastfeeding in 1981.

� Indian govt. adopted a National Code for Protection

& Promotion of Breastfeeding in 1983.

� IMS act was passed in 1992.

� Major drawback in these was to promote exclusive

breastfeeding for 4-6 months,

� This was used as a lacunae by MNCs which started

promoting infant milk substitutes from 3rd month

onwards.

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� Landmark decision was taken in WHA May, 2001 (54.2) to

promote exclusive breastfeeding for first 6 months.

� IMS act was also ammended along the same line to extend

exclusive breastfeeding to 6 months and bringing infant foodsat par with infant milk substitutes in so far as advertising,

promotion and other regulation are concerned.

�

Ammended in 2003 and implemented from 1

st

Jan 2004

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` A new resolution on Infant & Young Child Nutrition(55.2

WHA) was adopted in May 2002 by 55th WHA.

` ³ Breastfeeding is an unequalled way of providing ideal

food for healthy growth & development of infants; it is also

an integral part of reproductive process with important

implications for health of mothers. As a global publichealth recommendation, infants should be exclusively

breastfed for first six month of life to achieve optimal

growth, development and health. Thereafter, to meet their

evolving nutritional requirements, infants should receive

nutritionally adequate & safe complimentary foods whilebreastfeeding continues for upto two years of age or

beyond´- WHO, 2002.

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` National guidelines on IYCF launched 6 August, 2004

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` Intensify nutrition and health education to improve infant and

child feeding and caring practices so as to:

a. bring down the prevalence of under-weight children under

three years from the current level of 47 per cent to 40 per

cent;

b. reduce prevalence of severe Undernutrition in children in

the 0-6 years age group by 50 per cent;

10th Five year Plan

GOALS

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50.0%

80.0%75.0%

15.8%41.2% 33.5%

40%60%

80%

Exclusive

breastfeeding

(0-6 months)

Complementary

feeding (6-9 months)

100%

80%

NFHS-2NFHS-2 N H N

Initiation of

Breastfeeding

within 1 hr

xclusive

breastfeedingComplimentary feeding

60%

40%

20%

0%

1 th Five year lan

S

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` to advocate the cause of infant and young child nutrition

and its improvement through optimal feeding practicesnationwide

` to disseminate widely the correct norms of breastfeedingand complementary feeding from policy making level to the

public at large in different parts of the country in regionallanguages

` to help plan efforts for raising awareness and increasingcommitment of the concerned sectors of the Government,national organisations and professional groups

` to achieve the national goals for Infant and Young ChildFeeding practices set by the Planning Commission for theTenth Five Year Plan so as to achieve reduction in malnutritionlevels in children.

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A. Technical Guidelines

` 1. Breastfeeding

` 2. Complementary feeding

` 3. Feeding in the context of HIV infection

` 4. Feeding in other specific situations

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B . Operational Guidelines

` 1. Recommendations for Governmental andInternational Agencies

` 2. Role of NGOs

` 3. Recommendations for the media.

` 4. Training recommendations

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Nutritional superiority of breast milk

` best natural food for babies.

` always clean.

` protects the baby from diseases.

` makes the child more intelligent.

` available 24 hours a day and re uires no special preparation.

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` Breast milk is nature¶s gift to the infant and does not need to

be purchased.

` Breastfeeding makes a special relationship between mother

and baby.

` Breastfeeding helps parents to space their children.

` Breastfeeding helps a mother to shed extra weight gained

during pregnancy.

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` the baby should receive the first breastfeed as soon aspossible and preferably within half an hour of birth.

` To establish successful lactation as well as for providing

µColostrum¶.

` New born baby is very active during the first half anhour and if the baby is kept with the mother and effort ismade to breastfeed, the infant learns sucking very fast.

` Skin to skin contact between the mother and new bornshould be encouraged by µbedding in the mother andbaby pair¶.

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` No prelacteals should be given.

` The new born should be kept warm by promoting K angarooMother Care and promoting local practices to keep the room

warm.

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` more protein (upto10%) ; less fat and carbohydrate

` the f irst immunisation a child receives.

` Some mothers consider this first milk as something

dirty and indigestible.

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` babies are given only breast milk and nothing else ± no other

milk, food, drinks and not ever water for first 6 months.

` must be remembered that benefits of breastfeeding are

reduced if it is not exclusive breastfeeding.

` saves babies from diarrhoea and pneumonia. It also helps in

reducing specially the ear infections and risk of attacks of

asthma and allergies.

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` Addition of even a single feed of the animal or powder

milk, any other food or even water has two

disadvantages;

1) reduces lactation

2) inc. chances of infection

` No Bottles, Artificial

Teats or Pacifiers for

Breastfeeding Infants

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4.62

2.49

3.04

2.48

2.8

0

1

2

3

4

iarr eartality

Pne niartality

Diarr eainci ence

Pne niainci ence

ll ca sertality

Ex, r

. f

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` Baby should be fed ³on cues´.

` Working mothers should be encouraged to continue

exclusive breastfeeding for 6 months by expressing milk for

feeding the baby while they are out at work.

` The concept of ³Hirkani¶s rooms´ may be considered at

work places.

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` Ever y t er, s ecially t e first ti e t er s l receive

bre stfee i s rt fr t e ct rs and t e nursing

staff, r community ealt or ers regar ding c rrect

siti i , l tc i and treatment of r oblems, such as

breast engor gement, ni le fissures, etc.

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` Mouth wide open

` Lower lip is turned outside

` Chin touching the breast

`

areola not visible below thelower lip

` areola and nipple includingmilk collecting ducts areinside baby¶s mouth

` Tongue under the teat

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` Expectant mothers, particularly primiparas, and those who

have experienced difficulties with lactation

management, should be motivated and prepared for early

initiation of breastfeeding and exclusive breastfeeding.

` In the last trimester of pregnancy, breasts and nipples should

be examined and relevant advice given.

` Antenatal checkups and maternal tetanus toxoid immunisationcontact points should be utilised.

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`

The purpose of complementary feeding is to complement the breast milk and make certain that the young child continues to

have enough energy, protein and other nutrients to grow

normally.

` Roasted flour of any cereal can be mixed with boiled

water, sugar and a little fat to make the first complementary

food for the baby.

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` Complementary food should be :

1. Culturally acceptable

2. Ade uate to provide all nutritional re uirement

3. Locally available & inexpensive

4. Easily prepared at home

5. Physiologically suitable, easily digestable & nourishing

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Energy Density of Infant Foods

` can be increased in four different ways:

1. By adding a teaspoonful of oil or ghee in every feed.

2. By adding sugar or jaggery

3. By giving malted foods(Amylase Rich Flour)

4. By feeding thick mixtures.

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Instant Infant Foods

three parts of any cereal (rice/wheat) or millet (ragi, bajra jowar )

+

one part of any pulse (moong/channa/arhar )

+

half part of groundnuts or white til , if available

` Roast each of these seperately, mix & store in airtight

containers.

` For feeding, take two tablespoons of this infant food mix, add

boiled hot water or milk, sugar or jaggery and oil/ghee and

mix well.

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Fre e c f fee i

AGE TEXTURE FREQUENCY

AVERAGE

AMOUNT OF EACH MEAL

6-8 months Start with thick

porridge, well

mashed foods

2-3 meals per day

plus fre uent

breastfeeding

Start with 2-3

tablespoonfuls

9-11 months Finely chopped or

mashed foods, and

foods that baby

can pick up

3-4 meals plus

breastfeed,

Depending on

appetite offer 1-2

snacks

½ of a 250 ml

cup/bowl

12-23 months Family foods,chopped or mashed

if necessary

3-4 meals plus breastfeed,

Depending on

appetite offer 1-2

snacks

3/4 to one 250 mlcup/bowl

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Acti e fee i

` Adopting caring attitude hile feeding the ba by li e tal ing to the child, playing ith the child stimulates a ppetite and

development.

` ne-t o year old child should be given f ood on a

se parate plate and encouraged to eat on its own.

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` Hands should be washed with soap and water before handling

the food

` Utensils used should be scrubbed, washed well, dried and kept

covered.

` Cooking kills most germs

` After cooking, handle the food as little as possible and keep it

in a covered container protected from dust and flies.

` Cooked foods should not be kept for more than one to two

hours in hot climate unless there is a facility to store them at

refrigeration temperature.

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Gr t it ri r ti (GMP)

`

Infants and young children should bewe

ied

eve

r tin the presence of their mothers and the gr owth status of the

child should be explained to the mother.

` If the child is having mal triti , the mothers should be

advised to r vide additi al f d to the child ever y day.

` Malnourished children should be f ll wed at me and

mothers encouraged to come and as questions regar ding the

feeding and care of the child.

` Utilising the availa ble nutriti n and ealt services

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15.8

41.2

35

24.5

46.4

56.7

40.246.4

23.9

0

20

40

60

Initiation of

Breastfeeding within 1hour of birth

Exclusive breastfeeding

(0-6 months)

Complementary Feeding

(6-9 months)

NFHS-2 (98-99) NFHS-3 (2005-06) DLHS-3 (2007-08)

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Initiation of BF within

1 hour

Exclusive breastfeeding

RED 138(0-29%) 112 (0-11%)

YELLOW 197(30-50%) 373(11-49%)

BLUE 194(50-90%) 49(50-89%)

GREEN 5(90% or above) 0( 90% and above)

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0 1 0

2 0

3 0

4 0

5 0

6 0

7 0

Mizoram

Goa

MeghalayaManipur

Kerala

Tamil Nadu

Arunachal

Orissa

Maharashtra

Nagaland

Assam

Himachal

Sikkim

Karnataka

Tripura

UttaranchalJ&K

Gujarat

Chattisgarh

West Bengal

INDIA

Andhra

Haryana

Delhi

MP

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0 1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

Kerala

Sikkim

Mizoram

Manipur

Tamil Nadu

Arunachal

Meghalaya

Karnataka

Nagaland

Goa

Orissa

Himachal

Jharkhand

Andhra

Delhi

Tripura Assam

J&K

Bihar

Gujarat

West Bengal

INDIA

Chattisgarh

MP

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INDICATOR %

INITIATION OF BREASTFEEDING WITHIN 1

HOUR

8.9%

EXCLUSIVE BREASTFEEDING 5. %

COMPLIMENTARY FEEDING 4.4%

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5145

4340

2023

0

10

20

30

40

50

60

Stunted Underweight Wasted

NFHS-2 NFHS-3

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Child n und g y s who und w ight

6 6

6

6

66

S K

M Z

M N

K E

P J A

N A

J K

D L

T N

A P

A R

A S

H P

M H

K A

U T B

H R

T R

R J

O R

U P I N G

J C H

M G

B H

J H

M P

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7479

45

0

10

20

30

40

5060

70

80

90

Any anaemia Severe anaemia

NFHS-2 NFHS-3

Anaemia among Children Age 6Anaemia among Children Age 6--35 Months35 Months

Percent

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Anaemia revalenceAnaemia revalence tatetate

Anaemia prevalenceAnaemia prevalence

more than 70 percentmore than 70 percent

Bihar Bihar adhya rade hMadhya rade h

Uttar rade hUttar rade h

Har yanaHar yana

Chhattisgar hChhattisgar hAndhra radeshAndhra radesh

KarnatakaKarnataka

harkhandharkhand

Anaemia prevalenceAnaemia prevalence

Less than 50 percentLess than 50 percent

GoaGoaManipur Manipur

MizoramMizoram

KeralaKerala

Anaemia Is WidespreadAnaemia Is Widespread

throughout Indiathroughout IndiaChildren age 6-59 months

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79

85

56

6873

47

5762

42

Ur R r l T al

NFHS-1 NFHS-2 NFHS-3

NFHS-3, India, 2005-06

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62

54

52

42

35

72

63

55

51

42

78

78

55

59

44

BCG

Polio3

DPT3

M le

All V ine

NFHS-1 NFHS-2 NFHS-3 NFHS-3, India, 2005-06

Percent of children age 12-23 months vaccinated

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` 2006 guidelines suggested that health workers should

individually counsel all HIV positive mothers and help themeach determine the most appropriate infant feeding strategy for

their circum-stances.

` National health authorities have to decide whether they willrecommend that all HIV infected mothers will breast f eed and

receive ARV interventions OR will avoid all breast f eeding.

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` WHO recommendations advocate that all mothers known to be

HIV-infected should be provided with antiretroviral therapy

or antiretroviral prophylaxis to reduce mother to child

transmission and in particular to reduce postnatal transmission

through breastfeeding.

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mothers who are known to be HIV negative

OR

HIV status is unknownOR

infants of HIV +ve mothers known to be HIV-infected

exclusively breastfeed their infants for the first six months of

life and then introduce complementary foods while continuing

breastfeeding for 24 months or beyond.

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HIV+ve mothers on ARV therapy or prophylaxis

(whose infants are HIV-ve or of unknown HIV status)

exclusively breastfeed for the first 6 months of life, introducing

appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life.

Mother on zidovudine prophylaxis«.. baby should receive

daily Nevirapine from birth until one week after all exposureto breast milk has ended

Mother on tripple ARV prophylaxis..... Nevirapine from birth to

6 weeks

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` Whenever I -infected mothers decide to stop

breastfeeding, it should be done gradually within one month.

` If a I positive mother chooses not to breastfeed in s pite of

receiving ARV pr ophylaxis

` Zidovudine or evira pine is indicated f or wee s f or the ba by

fr om birth.

R e placement feeding

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` the process of feeding a child who is not receiving any breast

milk, with a diet that provides all the nutrients until the child is

fully fed on family foods.

` AFASS criteria must be completely fulfilled

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` Cup feeding should be the method of choice

`

If any of the AFASS criteria is not met

` exclusive breastfeeding till 6 months along with early

treatment of breast and nipple problems of HIV+ve mother.

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` For infants less than 6 months of age

(i) Expressed, heat-treated breast milk

(ii) Unmodified animal milk

(iii) Commercial infant formula milk.

` For children over 6 months of age

(iv) All children can be given complementary

food from six months of age

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` Other options for all ages

(v) Breastfeeding by another woman who is HIV

negative (wet-nursing)

(vi) Human milk from breast milk banks

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Feeding during sickness

` continue to breastfeed

` encourage to eat small uantities of nutrient rich food but

more fre uently.

` After the illness the nutrient intake of child can be easilyincreased by increasing one or two meals in the daily diet for a

period of about a month.

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Infant feeding in maternal illnesses

` breast abscess and mastitis and psychiatric illnesses which pose a danger to the child¶s life

` Treatment of primary condition

` breastfeeding started as soon as possible.

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` Chronic infections like tuberculosis, leprosy, or medical

conditions like hypothyroidism

` Continue breastfeeding

` treatment of the primary condition

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` Breastfeeding is contraindicated when the mother is receiving

certain drugs like antineoplastic agents, immuno-suppressants & antithyroid drugs

` Breastfeeding may be avoided when the mother is receiving

following drugs - atropine, reserpine, psychotropic drugs.

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Infant feeding in various conditions related to the infant

` very LBW, sick, or depressed babies

` expressed breastmilk through intra-gastric tube or with the use

of cup and spoon

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` Gastro-Esophageal Reflux Disease (GERD)

` fre uent small, thickened feeds and upright positioning for 30

minutes after feeds.

` Galactosemia

` absolute contraindication to breastfeeding

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Feeding During Emergencies

` Infants and young children are among the most vulnerable

victims of natural or human induced emergencies.

` Emphasis should be on protecting, promoting and supporting

breastfeeding and ensuring timely, safe and appropriate

complementary feeding.

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1) Recommendations f or Governmental and International

Agencies

` Global legislation, binding to all states and private

organizations including labor benefits.

` regular advertisements in state, public or private owned

audiovisual and print media

` implementation of the provisions of Infant Milk Substitute

(IMS) Act

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` Lactation counsellor at least at Block level

` Government along with International agencies shouldformulate National policy on Fortification of food with

micronutrients.

` The experts, academicians and government shallformulate/develop guidelines for management of Severe Acute

Malnutrition

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2 ) ROLE OF NGOS

3 ) RECOMMENDATIONS FOR MEDIA

4 ) RECOMMENDATIONS FOR TRAINING

` all the community health workers, PPTCT counsellors, and

other personnel caring for children including doctors should

undergo three days skill training on IYCF (including IMS

Act).

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` IYCF should also be included in the curriculum of

undergraduate and postgraduate medical education, nursing

education, home science, child nutrition courses etc.

` Anganwadi workers, ASHA, Daiµs and other grass root levelworkers should be empowered by basic, scientific information

related to IYCF.

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Thank you!

malik iycf

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