Breastfeeding: The 1st Hour Save ONE Million Babies Dr. Arun Gupta MD FIAP Founder and National Coordinator Breastfeeding Promotion Network of India (BPNI) and Regional Coordinator IBFAN Asia Breastfeeding: The 1st Hour Save ONE Million Babies WBW 2007 1/16/2019

Breastfeeding: The 1st Hour Save ONE Million Babies This PPT has been prepared for the Web Conference on Breastfeeding GOLD 2007, on the theme Breastfeeding the 1st Hour : Save 1 Million babies, the theme of WBW 2007. Dr.Arun Gupta MD FIAP, India WBW 2007 1/16/2019

How babies do in 1st minutes of life Lets see the video clip This video clip is done in Vietnam, where I was on a visit to analyse the policy and programmes on breastfeeding in the year 2003. Taken with permission of the mother, just after birth we saw how a baby actually makes efforts and cries to reach for her mothers nipple. WBW 2007 1/16/2019

Outline Objectives and background Little bit about history Scientific evidence Importance of the theme Call for a Worldwide response : what next ! WBW 2007 1/16/2019

Beginning Breastfeeding within ONE hour :Beginning life with “life” Sometimes it is a matter of life or death for babies ! As new study clearly points out for the first time that timing of beginning breastfeeding is independently linked to survival of babies. This the key point of the presentation and discussion. WBW 2007 1/16/2019

Objectives To draw the attention of participants of GOLD 2007, on the theme of WBW 2007 Share some scientific data To explain how important it is to mainstream support during first hour to ALL mothers to save ONE million babies with just ONE action, just ONE hour support and just ONE message…. To seek support from and encourage participants to establish breastfeeding within ONE hour as key indicator of health progress by the local and national governments, international organisations and all other communities locally and globally. To seek support of participants to further the message and reach try to make a campaign on this issue. WBW 2007 1/16/2019

Background 36% of all child deaths are ‘neonatal’ Lancet Neonatal series recognised 16 interventions and exclusive breastfeeding is one Early initiation of breastfeeding within one hour was not on the list New study presents increased risk of neonatal deaths in addition to earlier data on exclusive breastfeeding Poor coverage of Initiation of breastfeeding within one hour of birth , only 1 in 3. Nov 2005 Lancet did an article on tracking of child survival interventions; Initiation of breastfeeding within one hour of birth was added in the newborn health section You would note that more than one third of all child deaths occur during first month of life and Lancet had clearly recognized that exclusive breastfeeding is one of the interventions that does matter. The data was presented at the child survival countdown conference in London as a Poster presentation. And in 2005 Lancet did recognise the value in newborn health indicators it was included as you see in yellow lines . It is also important to note that many countries do not report first hour breastfeeding rates, or they are not available. There are only about 30% of mothers begin breastfeeding within one hour. The data conclusively points out the neglect of this practice and grossly under supported mothers across the world. We will talk more on this later…when we see the state of Initiation of BREASTFEEDING within one hour. WBW 2007 1/16/2019

Little History and commitments Following slide will take you back to 1992 …. WBW 2007 1/16/2019

BFHI 1992 Step 4 was, “Help mothers initiate breastfeeding within a half-hour of birth” Lets recall 1992, BFHI the famous initiative launched worldwide, one of the 10 steps was on initiation breastfeeding within one hour. This step -4 actually called for support within a health care institution to make it happen .Why have we failed?(OPINION) More than 15 years later see where we stand ?. Is it enough for launching a campaign worldwide to gather at least 1 million people calling for this help.(Yes/No) WBW 2007 1/16/2019

World Summit for Children Commitments Millennium Development Goals (MDG) 4 calls for U-5 child mortality to go down to HALF by 2015. UNICEF priority is in 60 countries ( U5MR>90/100live births, or No. of U5 deaths >50,000 These 60 countries account for 91% of all neonatal deaths Almost all neonatal deaths occur in developing countries Lets se what are we committed to ! MDG 4 on child survival : The progress is slow in most countries.,91% of all neonatal deaths occur in these 60 countries which are UNICEF priority countries having most child deaths. This shows need of widespread action. if about 36% of all child deaths are neonates, don’t you think there is a need to scale action to reduce neonatal deaths? What's that action , the following slides that provide scientific evidence that may make it more clear to all including the policy makers or programme managers WBW 2007 1/16/2019

Ghana Study findings and other evidence WBW 2007 1/16/2019

Six times more risk of death Risk of neonatal mortality according to time of initiation of breastfeeding Six times more risk of death This is in addition to earlier data set on child survival In addition to the survival value of breastfeeding in addition to shown by the Lancet series in 2003, new evidence from Ghana study points out that if ALL mothers begin breastfeeding within one hour 22% of newborn deaths can be cut. Mortality of newborn babies increases 6 times, if it is delayed to 72 hours. Lets see what it means in numbers in the next slide… Pediatrics 2006;117:380-386 WBW 2007 1/16/2019

1st hour initiation cuts 22% of all deaths INITIATION OF BREASTFEEDING If we enhance initiation of BF within one hour 30% 100% NEONATAL DEATHS SAVED The study suggests if we are able to increase initiation rates for ALL babies, more than 1 million newborn deaths could be reduced, meaning a major contribution it can make to achieving the national goals to reduce IMR , U5MR and the MDG4 How the authors have done the calculation may be the next question you all would be wanting to know. 4 million 1 million Pediatrics 2006;117:380-386 WBW 2007 1/16/2019

Potential Mechanisms Suckling shortly after birth have a greater chance of successfully establishing and sustaining breastfeeding throughout infancy. However, the effect of early initiation persisted after controlling for established neonatal breastfeeding patterns. Early feeding with non human milk proteins may severely disrupt normal gut function Rich immune and non-immune components that are important for early gut growth and resistance to infection. Promotion of warmth and protection may reduce the risk of death from hypothermia. In this slide potential mechanism is explained. The authors of the Ghana study also explain the "Potential Mechanisms". Early initiation of breastfeeding could affect neonatal mortality risk by at least four mechanisms, the lower rate of mortality in those who initiated early may have occurred because mothers who suckle their babies shortly after birth have a greater chance of successfully establishing and sustaining breastfeeding throughout infancy. However, the effect of early initiation persisted after controlling for established neonatal breastfeeding patterns. Secondly, early feeding with non-human milk proteins may severely disrupt normal gut function; thirdly, early human milk is rich in a variety of immune and non-immune components that are important for early gut growth and resistance to infection. Fourthly, promotion of warmth and protection may reduce the risk of death from hypothermia. WBW 2007 1/16/2019

Key findings of the study Sample more than 10,000 babies 30% of the study population initiated breastfeeding after day 1 (late initiation) 30% were not exclusively breastfed in the neonatal period Exclusive breastfeeding was associated with a 4 fold reduction in risk of death when compared to infants who were fed solids or other milk. This confirms previous findings. Key findings of the study include: 30% of the study population initiated breastfeeding after day 1 (late initiation) and 30% were not exclusively breastfed in the neonatal period, Exclusive breastfeeding was associated with a 4 fold reduction in risk of death when compared to infants who were fed solids or other milk, which confirms previous findings. WBW 2007 1/16/2019

Importance of Findings An additional 2.5 fold reduction in risk of death was demonstrated in babies who survived to day 2 who initiated breastfeeding on the first day of life (early initiation) compared to infants who initiated after the first day of life (late initiation). This type of effect of early initiation has never been reported. An additional 2.5 fold reduction in risk of death was demonstrated in babies who survived to day 2 who initiated breastfeeding on the first day of life (early initiation) compared to infants who initiated after the first day of life (late initiation). This type of effect of early initiation has never been reported.Translating these benefits to the whole population of neonates (breastfed and not breastfed) means that 16% of neonatal lives can be saved if all babies were breastfed from day 1, and 22% if breastfeeding were started within the first hour. Neonatal mortality was also shown to increase markedly with delay in beginning breastfeeding. Recall the earlier graphic ! And further discussion will reveal the potential survival value. According to the authors such an effect of timing of first breastfeeding on child survival has not been reported earlier and thus makes an addition to existing data on child survival. The data was not there when Lancet series did the work in 2003. WBW 2007 1/16/2019

What it means? Translating these benefits to the whole population of neonates (breastfed and not breastfed) means that 16% of neonatal lives can be saved if all babies were breastfed from day 1, and 22% if breastfeeding were started within the first hour. WBW 2007 1/16/2019

Global impact of increases in coverage and promotion of early initiation of breastfeeding in less developed settings. Projected absolute numbers of lives saved and the proportion of neonatal deaths avoided if 99% of infants initiated breastfeeding during the first hour or during the first day of life. ** Only 38 of the 60 countries had data available on initiation of breastfeeding within 1 hour and 1 day of birth. The neonatal mortality rate for these 38 countries ranged from 15-70/1,000 live births. For rest of 22 countries regional averages were used **Karen M Edmond, Ellie C Bard, Betty R Kirkwood, Meeting the millennium development goals for child survival: global impact of early initiation of breastfeeding on neonatal mortality. (Un published) This presentation was made at the Child Survival Countdown in London 2005, s a poster. WBW 2007 1/16/2019

Authors’ Intervention Models A and B : Lives saved estimated for universal coverage: 99%, and 90% A : BF initiated within one hour 99% : 1.11 million lives saved, 31% of all newborn deaths, and 11% of U5 child deaths 90%: 0.972 million lives saved, 27% of all newborn deaths and 10% of U5 child deaths B: BF initiated within one day 99% : 0.866 million lives saved, 24% of all newborn deaths, and 9% of U5 child deaths 90%: 0.680 million lives saved, 19 % of all newborn deaths and 7% of U5 child deaths WBW 2007 1/16/2019

Risk of newborn deaths BF Initiated Ad OR Attributable Risk 1st hour 1 - Day 1 , later 1.44 31% After Day 1 2.88 65.3% Day 1 vs. later 2.40 58.3% This slide shows the details of how they reached these numbers, with 2 models. They calculated attributable risks. WBW 2007 1/16/2019

Concluding finding Neonatal mortality could be reduced by 24% if 99% of infants initiated breastfeeding on day 1 of life and by 31% if 99% of initiation was within the first hour. Numbers of lives saved were estimated to be 867,000 and 1,117,000 in these two cases." The model is based on a single dataset; Similar data from other countries should be collated/collected as a priority. If risks from Ghana are confirmed EARLY BF initiation should be added to key child survival interventions & monitored. Potentially about 30% of newborn deaths (10% of U5 deaths) might be prevented with universal coverage of BF initiation within the 1st hour The paper goes logically from one step to the next to show that, in global terms, over one million lives would be saved if all newborns younger than one month were breastfed within the first hour of life. They concluded that promotion of early initiation of breastfeeding has the potential to make a major contribution to tackling the millennium development goal for child mortality. They called for policy changes to effect promotion, coverage and reporting of early initiation of breastfeeding, as well as exclusive breastfeeding, which must improve at all levels; global, national and sub national. WBW 2007 1/16/2019

Other benefits of the ONE hour !!! WBW 2007 1/16/2019

Benefits to both women and babies Nourishment and its first immunisation. Production of milk enough for the next feed. It makes use of the baby’s sucking reflex (which is strongest during the 1st hour) to establish proper latching. Prevent blood loss in the women. Provides the skin-to-skin contact and warmth that babies need most, particularly premature and low birth weight babies. It is more beneficial for low weight babies because they are more likely to die, and they need more support at birth to be able to suck well. Early skin-to-skin contact and the opportunity to suckle within the first hour or so after birth are both important. Some contact cannot be avoided when attempting breastfeeding but contact itself does not necessarily result in immediate suckling. Mothers need to be supported for achieving both contact and suckling which are so closely interrelated. It has an important bearing on survival and development of babies. The infant who is in close contact with its mother can suckle when it shows signs of readiness, such as suckling movements, which are often present during the first hour of birth. It has been observed that the suckling reflex of the newborn is at its height twenty to thirty minutes after birth. If the infant is not fed then the reflex diminishes rapidly only to reappear adequately forty hours later. This may be called “ The fourth stage of labour” which includes putting the baby to breast after birth and ensuring the intake of colostrum by the neonate. The exact time of initiation of breastfeeding has been suggested right from birth in the delivery room itself to about an hour after delivery. Also the antibody content of colostrum is at its maximum during the first twelve postpartum hours making it relevant. Early breastfeeding has a physiological effect on the uterus as well, causing it to contract . The effect of skin-to-skin and suckling contact immediately after birth increases the median duration of breastfeeding by 2 ½ months.In a sample of Norwegian infants, 69% of those who were suckled at birth were still being nursed at the age of 3 months, compared to only 47% of those who were first suckled after six hours. WBW 2007 1/16/2019

How to help women to begin breastfeeding within the 1st hour? Women need minimum essential support to succeed tin exclusive breastfeeding including early breastfeeding e.g. assistance at time of birth to initiate the process of breastfeeding help and a policy to keep the baby and mother together after delivery avoidance of giving pre-lacteal feeds and artificial nipple/teats Accurate information Breastfeeding education and counseling during pregnancy Maternity benefits like leave and cash benefits for poor women and Crèches WBW 2007 1/16/2019

Where we stand ? Initiation of breastfeeding within ONE hour In 38 countries : 26-52 (36 median) South Asia worst hit , but needed most WBW 2007 1/16/2019

The State of World’s Initiation of breastfeeding Mapping Information Blank /No colour: Data not reported/available 2. Red: Initiation of breastfeeding within one hour rate Below 29% 3. Yellow: Initiation of breastfeeding within one hour rate 30-49% 4. Blue: Initiation of breastfeeding within one hour rate 50-89 % 5. Green: Initiation of breastfeeding within one hour rate 90% or more The report card is the result of IBFAN Asia effort to develop and disseminate State of World Breastfeeding report cards. WBW 2007 1/16/2019

Why World Breastfeeding Week(WBW):2007 for ONE hour support Currently this is not a key indicator UN reports on child nutrition like UNICEF’s annual SOWC Other global and national reports. Do you think It should be reported periodically an all child health reports ? Do you think it should become a standard of care in a health care setting? WBW 2007 1/16/2019

What next? Advocacy for support to mothers during 4th stage of labour Policy : Coverage, promotion and reporting should improve along with exclusive breastfeeding for 0-6 months. Services: BFHI should make at least this as doable intervention and as a “standard of good hospital practice” Family level: All women should be supported at birth at home/ family level and increased awareness of family members is required to create suitable environment WBW 2007 1/16/2019

What next? Similar data sets are needed from other countries ‘Breastfeeding education and support’ should be considered a key child survival intervention and placed equal to immunization’ Policy, programmes, services and family level support should be made available as an entitlement Campaign to get people thinking about it, Women and men, Youth in particular Internet campaign on listing support by 1 million people over next 3 - years: can we do it? Campaign , to call upon the Peoples representatives, by the people, “We care for support women to save babies’, Do you?” WBW 2007 1/16/2019

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Thank you for listening ! WBW 2007 1/16/2019