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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 & (Global strategies for Infant &
Young Child Feeding) Young 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 Infant feeding RecommendationsRecommendations
(Global strategies for Infant & (Global strategies for Infant & Young Child Feeding) Young Child Feeding)
• Preterm, ELBW, VLBW and above 1600gm. All need breastmilk.
• Feeding method and approaches are varied.
Slide 4
HIV :2000 and 2006 WHO HIV :2000 and 2006 WHO RecommendationsRecommendations
• Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months 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 – 6 yrs )ICDS (??? 0 – 6 yrs )
3326 23 20 18 16
0
10
20
30
40
50
60
70
80 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 Why Breast milk for preterm 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
LDL
to H
DL
ratio
Slide 12
Lancet 2004;363:1571-8 Singhal A, Lancet 2004;363:1571-8 Singhal A, Cole TJ, Lucas A Breastmilk and Cole TJ, Lucas A Breastmilk and
Lipoprotein profile in adolescents born Lipoprotein profile in adolescents born preterm: Followup of a prospective preterm: Followup of a prospective
randomised study (n=926)randomised 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
Colostrum ( evidence Colostrum ( evidence class I-III )class I-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 of obesity in childhood at age five and six years, Germanysix years, Germany
4.5
3.8
2.31.7
00.5
11.5
22.5
33.5
44.5
5
months breastfeeding
Prev
alen
ce (%
)
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 I-II)Higher Intelligence quotient ( Evidence class I-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 FF
Study 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. Soc SciMed 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 Intervention Number (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 to the national economy in
IndiaIndia• 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 Comparative health care costs of treating breastfed and formula-fed treating breastfed and formula-fed
babies in the first year of life in a health babies in the first year of life in a health maintenance organization (HMO)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 never-In addition, the 1000 never-breastfed infants had:breastfed infants 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 infantduring 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
Slide 28
What is the infant mortality What is the infant mortality risk 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 - mother in law told her she didn’t have enough for 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
Models
No 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 Which photograph will increase TRP ?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 AdviceFeed 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
Slide 42
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 Two Most Common Complaints Complaints
“I don’t have enough milk”Find out why she thinks thisFind out if the baby is gainingInquire about baby’s urine outputInquire about what medications,including birth control meds that she
istaking 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 whatWe want to happen!
Slide 45
Two Most Common Two Most Common ComplaintsComplaints
“I have sore nipples”
Most common cause of sore nipple is poor positioning and latch Mothers want hands-on help withbreastfeedingMothers are NOT embarrassed by hands-on help
Slide 46
Slide 47
Slide 48
Two Most Common Two Most Common ComplaintsComplaints
“I have sore nipples”
If your help with positioning and latchdoesn’t improve the pain within 24-48hours, refer on!!!
Remember that the second most common reason for stopping breastfeeding is sorenipples…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