Dr. K P KushwahaProf & Head,

BRD Medical College, Gorakhpur

Evidence classification

Evidence class• Class I

• Class II

• Class III

Criteria for evidence• Randomized control trial

;at least one• Well organized control

trials without randomization, cohort or case control ,cross sectional, retrospective ;more than one

• Case reports, reports of expert comittees, guidelines,

Infant feeding RecommendationsInfant feeding Recommendations(Global strategies for Infant & Young (Global strategies for Infant & Young

Child Feeding) Child Feeding)

• Exclusive breastfeeding form birth to 6 months

• Appropriate complementary feeding after 6 months

+ Breastfeeding

• Sustaining breastfeeding for 2 years and beyond

• Related maternal, nutrition & care

• Building community support and health system

support protecting infant feeding practices from

commercial influences

Slide 3

Infant feeding RecommendationsInfant feeding Recommendations(Global strategies for Infant & Young (Global strategies for Infant & Young

Child Feeding) Child Feeding)

• Preterm, ELBW, VLBW and above 1600gm. All need

breastmilk.

• Feeding method and approaches are varied.

Slide 4

HIV :2000 and 2006 WHO RecommendationsHIV :2000 and 2006 WHO RecommendationsHIV :2000 and 2006 WHO Recommendations

• Exclusive breastfeeding is recommended for HIV-infected women for the first 6months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time.

• When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected women is recommended

•When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended.

• Otherwise, exclusive breastfeeding is recommended during the first months of life.

Slide 5

IYCF Practices-India

• Initiation with in 1 Hr

• Exclusive Breastfeeding

• Timely (appropriate ?) complement

• Sustained breastfeeding 2 years and beyond

• 23.4

• 46.3

• 55.8

• 38.4

Source: NHFS-3

Slide 6

(Squeezing and discarding of colostrum and prelacteal feeds are quite common)

Trends in Nutritional StatusTrends in Nutritional Status

40

23

45 43

20

51

UnderweightWastedStunted

NFHS-3 NFHS-2

Percent of children age under 3 years

(Low-height-for-age) (Low-weight-for-height) (Low-weight-for- age)

Slide 7Source: NHFS-2 & 3

Anaemia among Children

7479 81

72

Total Urban Rural NFHS-2

Percent of children 6-35 months with anaemia

Slide 8

How Many Children Receive Services from an AWC? ICDS (??? 0 ICDS (??? 0 –– 6 yrs )6 yrs )

3326 23

20 18 16

0

10

20

30

40

50

60

70

80

Any se

rvice

Supplem

enta

ry fo

od

Pre-s

chool

Imm

unizatio

nsGro

wth m

onitorin

gHea

lth c

heck-

ups

Percent of age-eligible children in areas with an AWC

Slide 9

How many 0-6 ms are being looked after?

Source: NHFS-3

Benefits to Baby (evidence class I –III)

• Optimum growth

• Brain growth

• Reduce risk for:

– Undernutrition

– Upper and lower respiratory infections

– Otitis media (ear infections)

– Urinary tracts

– Sytemic Infections

– Gastroenteritis

– Allergies

– Overweight/obesity

– SIDS

Slide 10

Why Breast milk for preterm Why Breast milk for preterm

• To Protect

- Infections

- NEC

• To Provide

- PUFA, growth factors, hormone, tropic factors

- Better visual and cognitive development

• To Involve mother in care, including KMC

• To Provide nutrition's with high bio availability

Slide 11

Evidence class I

1

1.2

1.4

1.6

1.8

2

2.2

2.4

2.6

2.8

Lowest 3rd (13%) Middle Third (65%) Highest Third (100%)

Human Milk Intake

LD

L to

HD

L rat

io

Slide 12

Lancet 2004;363:1571Lancet 2004;363:1571--8 8 SinghalSinghal A, Cole TJ, Lucas A, Cole TJ, Lucas

A A BreastmilkBreastmilk and Lipoprotein profile in and Lipoprotein profile in adolescents born preterm: adolescents born preterm: FollowupFollowup of a of a prospective prospective randomisedrandomised study (n=926)study (n=926)

Evidence class I

Breast milk composition differences (dynamic)

• Gestational age at birth(preterm and full term)

• Stage of lactation(colustrum and mature milk)

• During a feed(foremilk and hindmilk)

Slide 13

Evidence class I

Slide 14

Slide 15

ColostrumColostrum ( evidence class I( evidence class I--III )III )

Property• Antibody- rich

• Many white cells• Purgative

• Growth factors

• Vitamin- A rich

Importance

• protects against infection and allergy

• protects against infection

• clears meconium; helps prevent jaundice

• helps intestine mature; prevents allergy, intolerance

• reduces severity of some infection (such as measles and diarrhoea); prevents vitamin A- related eye diseases

Slide 16

Slide 17

More Benefits to Baby(When they grow)

• Reduced risk for:

- Dental disorders

– Diabetes

– Crohn’s disease

– Childhood Leukemia

– Cardiovascular disease

– Celiac disease

– Rheumatoid arthritis

Slide 18

Evidence class II -III

Benefices for Mom

• Rapid recovery after having a baby

• Decreases risk of anemia

• Weight reduction

• Reduces risk of breast cancer

• Reduces risk of ovarian cancer

• May reduce risk of endometrial cancer

• Reduces risk for osteoporosis

• Delays next pregnancy

Slide 19

Evidence class II -III

Community Community

BenefitsBenefits

New parents missLess work

Fewer healthcareVisits & lower Treatment costs

Breast milk is aNatural andRenewableresource

Slide 20

Evidence class III

Breastfeeding prevents under nutrition and obesity

Under nutrition 40-50%

Obesity 50%

Evidence class II-III

Breastfeeding decreases the prevalence Breastfeeding decreases the prevalence

of obesity in childhood at age five and six years, of obesity in childhood at age five and six years, GermanyGermany

4.5

3.8

2.3

1.7

00.5

11.5

22.5

33.5

44.5

5

months breastfeeding

Pre

vale

nce

(%

)

0 months2 months3-5 months6-12 months

Adapted from: von Kries R, Koletzko B, Sauerwald T et al. Breast feeding and obesity: cross sectional study. BMJ, 1999, 319:147-150.

Slide 22

Higher Intelligence quotient ( Evidence class IHigher Intelligence quotient ( Evidence class I--II)II)

BF 2.1 pointshigher than FF

Study in 6 monthsto 2 year- olds

1988

BF 8.3 pointshigher than FFStudy in 7.5-8year-olds

1992

BF 2 pointshigher than FFStudy in 3-7year-olds

1982

BM 7.5 pointshigher than no BM

Study in 7.5-8year-olds

1992

BF 12.9 pointshigher than FFStudy in 9.5year-olds

1996

References:

•Fergusson DM et al. SocSciMed 1982

•Morrow-Tlucak M et al.SocSciMed 1988

•Lucas A et al. Lancet 1992•Riva Eet al. Acta Paediatr 1996

BF = breastfedFF = formula fedBM = breast milk

Slide 23

Potential Child Mortality Reduction Potential Child Mortality Reduction from Preventive Interventions from Preventive Interventions

Jones et al. How many deaths can we prevent this year? Lancet 2003

Preventive InterventionNumber (thousands)

Deaths prevented as proportion of all child deaths

Breastfeeding 1301 13%

Insecticide-treated materials 691 7%

Complementary feeding 587 6%

Zinc 459 5%

H influenzae vaccine 403 4%

Antiseptic delivery 411 4%

Water, sanitation, hygiene 326 3%

Slide 24

The value of breast milk The value of breast milk

to the national economy in Indiato the national economy in India

• National production of breast milk by all mothers in India for the children they were breastfeeding at the time of the estimate was about 3944 million liters over 2 yrs.

• If the breast milk produced were replaced by tinned milk, it would cost 118 billion Rupees.

• If imported, the breast- milk substitutes would cost 4.7 million USD.

• If breastfeeding practices were optimal, breast milk production would be twice the current amount, doubling the savings by fully utilizing this “national resource”.

Adapted from: Gupta and Khanna. Economic value of breastfeeding in India. The National Medical Journal of India, 1999, May-June 12(3):123-7.

Slide 25

Comparative health care costs of treating breastfed Comparative health care costs of treating breastfed

and formulaand formula--fed babies in the first year of life in a fed babies in the first year of life in a health maintenance organization (HMO)health maintenance organization (HMO)

When comparing health statistics for 1000 never breastfed infants with 1000 infants exclusively breastfed for at least 3 months, the never breastfed infants had:

• 60 more lower respiratory tract illnesses

• 580 more episodes of otitis media, and

•1053 more episodes of gastrointestinal illnesses

Adapted from: Ball & Wright. Health care costs of formula-feeding in the first year of life. Pediatrics, 1999, April, 103(4 Pt 2):870-6.

Slide 26

In addition, the 1000 neverIn addition, the 1000 never--breastfed infants breastfed infants had:had:

• 2033 excess office visits

• 212 excess hospitalizations

• 609 excess prescriptions

These additional health care services

cost the managed care system

between $331 and $475 per never- breastfed infant

during the first year of life.

Adapted from: Ball & Wright. Health care costs of formula-feeding in the first year of life. Pediatrics, 1999, April, 103(4 Pt 2):870-6.

Slide 27

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What is the infant mortality risk What is the infant mortality risk

from not breastfeeding?from not breastfeeding?

WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant

and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000 Feb 5;355(9202):451-5.

Pooled Odds Ratios

0

2

4

6

8

10

12

0-1 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo 12-24 mo

Lowest tercile of mat. education

Ghana

Slide 29

The baby Killer The baby Killer

• Sale of formula in India Rs• Sale of Bottles in India Rs

(Andy Chetley/war on want, 1974)

Slide 30

Mother of Twin

Slide 31

Mother of twins - motherin law told her shedidn’t have enoughfor two, UNICEF 1992,

Mushtaq Khan

Artificial jewelry

Animal Milk

Real Gold jewelry

Breast milk Slide 32

How do we are compare

Cow with calf Mother Breastfeeding

Slide 33

NO?

No Correct

information

Lack ofEarly

Assistance

Embarrassed

Hospitalpractice

Work orschool

FearTied down

‘modern’way

Marketingof

formulaNo role

ModelsNo

confidence

No support

Why Mothers do not succeed?

Slide 34

Evidence class I-III

Manufacturing Malnutrition Are they parallel methods ?Are they parallel methods ?

Promoting best food for baby And where is miracle

• Benefits to –

– Manufactures

– Scientists

– Shareholders

– System

– Health workers

• At which cost ?

SalesSales Who its Who its productionproduction

• Who is benefited

• At which cost ?

Slide 35

• Community Practices

• Health system

• Commercial influences

• Work & employment

• Nutritional & health care

• Attitude

• Urbanization

• HIV & disaster

Confused mother Baby’s Misery

Slide 36

Marketing Confuses Mothers

Which photograph will increase TRP ?Which photograph will increase TRP ?

((Even Media is afraid of PromotingEven Media is afraid of Promoting BreastfeedingBreastfeeding))

Which photograph will create controversy ?

Malnourished baby & Malnourished baby &

mother mother A beautiful women A beautiful women

breastfeeding breastfeeding

Slide 37

Milk DonationsMilk Donations(What NGOs do for 0-6m nutrition?)

Slide 38

Role of International Health Role of International Health AgenciesAgencies

Pressure groups IBFAN

InternationalAssembly

of Infant food manufactories

• Mediator - Budget from 25% -US

• 70% from Industrialized countries

• How far taking strong stands on sensitive issues ??

Slide 39

What is Advice

Feed him on the left!

Feed him on the right!

Feed him in the morning,

Noon, and night!

Yeah! Breastfeeding!

Slide 40

What is promotion?

Slide 41

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What is support?

• How can we help?

• What will work for you?

• We have answers that will help you

• we can help by observing a feeding your baby

Slide 43

Two Most Common Complaints Two Most Common Complaints

“I don’t have enough milk”

Find out why she thinks this

Find out if the baby is gaining

Inquire about baby’s urine output

Inquire about what medications,

including birth control meds that she is

taking or has been given

Slide 44

When a mother thinks…When a mother thinks…

She does not have enough milk

Her first response is to supplement

with formula

This causes her supply to diminish

Exactly the opposite of what

We want to happen!

Slide 45

Two Most Common ComplaintsTwo Most Common Complaints

“I have sore nipples”

Most common cause of sore nipple is

poor positioning and latch

Mothers want hands-on help with

breastfeeding

Mothers are NOT embarrassed by hands-

on help

Slide 46

Slide 47

Slide 48

Two Most Common ComplaintsTwo Most Common Complaints

“I have sore nipples”

If your help with positioning and latch

doesn’t improve the pain within 24-48

hours, refer on!!!

Remember that the second most common reason for stopping breastfeeding is sore

nipples…so act quickly!!!

Slide 49

Effective Communication

Explore Feelings

Information,Options,

Suggestions

Respect

Identify &Praise right

things

Acceptwhat she

‘thinks’ or feels

Listencarefully

Ask open ended

questions

Provide Practical

Help

Slide 50

Evidence class I-II

New 2006 WHO GuidanceNew 2006 WHO Guidance((HIV and 0-6 Months)

• Exclusive breastfeeding does carry lower risk of HIV transmission than mixed feeding

• HIV-infected infants should continue to be breastfed• Repeated assessments of feeding choice with mother• Breastfeeding beyond 6 months may be best for some

HIV-exposed infants• Counselling should focus on 2 main options

(replacement feeding and exclusive breastfeeding for 6 months), with other local options discussed only if mother interested

• Home-modified animal milk no longer recommended for all of first 6 months – only to be used as short-term measure

Slide 51

•The state shall regard the raising the level of nutrition and the standard of living of it’s people and the improvement of public health as amongst it’s primary duties _ _.

Constitution of India, Article 47

Slide 52

• If you believe in the importance of breastfeeding to mother and baby and you have imagination and determination and develop the necessary skills ;

even in most difficult situations you may find a way _ _.

-ThanksThanks-

Slide 53