Why Breastfeeding? An Issue of Urgency in the Dynamic Global Situation Miriam H Labbok, MD, MPH, FACPM, IBCLC, FABM Professor and Director labbok@unc.edu CAROLINA BREASTFEEDING INSTITUTE DEPARTMENT OF MATERNAL AND CHILD HEALTH

Objectives 1. Better understand the contribution of breastfeeding to nutrition, health, development and survival 2. Present what is known on the trends in breastfeeding practices Highlight recent research, especially on issues that have contributed to policy and program change 4. Review recommendations on infant feeding in the context of HIV, emergencies, and other “hot” issues

Pop Quiz!!!! About how many children under age five will die in the world in the next 24 hours from preventable causes such as diarrhea, pneumonia and malaria, HIV? A. 5,000 B. 10,000 C. 15,000 D. 30,000 E. 50,000 CBI Labbok, 2009 With thanks to Sally Page Goertz for this subset of slides

The Question: Answer Of these 30,000, how many will die of HIV/AIDS? About 1000, or About 4% of preventable deaths CBI Labbok, 2009

How many of these deaths are preventable by Early and Exclusive Breastfeeding? Answer: About 4500, or About 15% of the preventable deaths CBI Labbok, 2009

Percent of U-5 Child Death Preventable By: 10/2008 Academy of Breastfeeding Medicine

What is “Optimal” feeding? WHO/Unicef “infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter... infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.” -Breastfeeding alone is sufficient and uniquely suited for the first six months of life -While the US recommends BF to 1 year of life, this is not in conflict with the WHO recommendation -There is remaining controversy between the AAP breastfeeding committee’s recommendations and the AAP nutrition committee’s recommendations, which are still EBF for 4-6 months

Immediate postpartum initiation Exclusive breastfeeding What is Optimal Breastfeeding? Family security – the underpinnings and best start on health and nutrition Immediate postpartum initiation Exclusive breastfeeding Complementary feeding and sustained breastfeeding Breastfeeding continues to provide essential micronutrients and energy. Active, responsive feeding Adaptation to family diet

Breastfeeding is the Heartbeat of Maternal/Infant Health Why Breastfeeding? Breastfeeding is the Heartbeat of Maternal/Infant Health Breastfeeding supports: Nutrition Oral Rehydration Family Health Growth and Development Birth Spacing and Fertility Immunization: Diarrhea/ Pneumonia/ Ear infections Reduced MTCT of HIV Reduced Cancer and Chronic Disease Maternal Health and Survival Logo, Breastfeeding Division, IRH

“PROMOTION” IS NOT ENOUGH! Protection Promotion AND Support

Everything you need to know about supporting breastfeeding clinically in one slide GUT Mesenteric lymph nodes Breast Hypothalamus Pituitary Ovaries -Comments?

Meta-analyses and Reviews 2007 Findings: Lack of breastfeeding significantly associated with an increase in the risk of acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), malnutrition, type 1 and 2 diabetes, childhood leukemia, increased blood pressure sudden infant death syndrome (SIDS), and necrotizing enterocolitis. 10/2008 Academy of Breastfeeding Medicine

Immediate Postpartum Breastfeeding is also part of optimal feeding Decreased Maternal stress Mezzacappa et al 2005 Enhanced uterine involution Negishi et al. 1999 At three months potpartum, most significant variable Decreased blood loss Bullough et al. 1989 Increases neonatal survival at least 2.4-fold Edmond K et al. 2006, Darmstadt ,2005 Appropriately delayed cord clamping Chaparro, Dewey et al various, 2007/8 10/2008

If you need more reasons… Maternal Health Growth/Satiety Intelligence and upward mobility Birth Spacing 10/2008

What will the new growth chart do … Partial or no breastfeeding, 0-4 mos. associated with underweight at 12 mos. Piwoz EG, et al. (Peru) At 6 mo., BF infants were heavier and taller Villalpando S, et al. (Mexico) Longitudinal study shows early formula spurt equalized by 2 yo, and no difference at adult height. Zadik Z, et al. (Israel) The impact of EBF for 3-5 mos. on growth was still detectable at 12 mos, even more significant in LBW. Arifeen SE, et al. 2001b. (Bangladesh) BW same in both groups, but study group with increased EBF had greater growth. Kramer MS, et al. 2002. (Belarus) Increase from 6.5- 54% EBF, at 6 months weight and length significantly higher in EBF. Froozani MD, et al. (Iran) -This impact on growth is the basis for the new WHO growth standards, which will be discussed in much greater detail later on CBI Labbok, 2009

Human milk was made for brain development Why should breastfeeding be associated with improved cognitive development? Human milk was made for brain development components enhance brain development Children learn with all their senses: Special smells and tastes of breastfeeding prepare infant for family foods Seeing and smelling mother and hearing her heartbeat Seeing what she does in all situations Natural touch and other sensations

The Lactational Amenorrhea Method -- LAM Ask the mother, or advise her to ask herself, these three questions: 1. Have your menses returned? 4. The mother’s chance of pregnancy is increased. For continued protection,and to achieve a healthy three years of child spacing, advise the mother to begin using a complementary family planning method and to continue breastfeeding with complementary feeding after 6 months . YES NO 2. Are you supplementing regularly or allowing long periods without breastfeeding, either day or night? YES YES NO 3. Is your baby more than six months old? The LAM algorithm is a codification of the Bellagio Consensus Statement. It is designed to reinforce the that there are 3 criteria that are necessary for efficacy, that there is a fourth parameter(the need to emphasize the use of another method to achieve at least 3 years of child spacing, and clear guidance as to how one might help the new acceptor understands the method. The return of menses is the most important reflection of fertility return and, hence is the most important criteria to remember. However, since ovulation may occur during amenorrhea in partially breastfeeding women, the pattern of feeding becomes equally as important for successful child spacing with LAM. The third criteria, 6 months, was based on the fact that supplementation is recommended at that time. Results of several studies lead us to believe that LAM may be extended well beyond 6 months if LAM is successfully practiced for the first 6 months, and if the frequency and intensity of breastfeeding is maintained after some supplementary feedings are begun. One way to ensure the continued physiology of breastfeeding is to breastfeed the infant just prior to giving the supplementary feed; breastmilk remains a major, and in many countries, a vital source of nutrition for 2 - 3 years of more. NO There is only a one to two percent chance of pregnancy at this time. When the answer to one of these questions becomes YES.... 10/2008

Could there be more reasons to protect, promote and support breastfeeding? Epigenetics Cost savings for families and the nation Reduced HIV transmission if EBF

A way to convince governments? Costs of Not Breastfeeding More than 15 billion dollars worldwide 10s to 100s of millions in scarce import dollars in some countries Thousands of dollars per hospital in reduced need for nursing staff, formula and oxytocin substitutes 10%-260% of annual minimum urban wage in selected countries Cost of mixed feeding twice that of EBF (India, Bhatnagar S, et al. ) Increasing death and disease outbreaks

Academy of Breastfeeding Medicine Cumulative probability of HIV among 549 children born to HIV+ women Coutsoudis et al. AIDS 2001, 15:379-87 Exclusively breastfed group ( ) is statistically significantly different from mixed fed ( ), but is not statistically significantly different from never breastfed ( )group until 15 months, controlling for 15 variables. 10/2008 Academy of Breastfeeding Medicine

Iliff P, Piwoz E et al. AIDS, 2005 Hazards Ratio for HIV Infection or Death from 6 weeks to 6, 12, and 18 months, by feeding pattern Controlled for Infant birth weight, and Maternal CD4 count, hemoglobin, death, marital status and Vitamin A treatment Definition death or infection at 6 mo. death or infection at 12 mo. death or infection at 18 mo. p Value EBF Only BM 1.0 Pre-dominant BM & non-milk liquids 2.42 (0.71,8.18) 2.36 (1.00,5.57) 1.73 (0.84,3.52) p<0.05 at 12 mo Partial/Mixed BM & non-human milk &/or solid food 3.03 (0.95,9.69) (1.34,6.86) 2.48 (1.26,4.84) p<0.06 at 6 mo., p<0.008 at 12 and 18 mo. Iliff P, Piwoz E et al. AIDS, 2005 10/2008 Academy of Breastfeeding Medicine

HIV-associated Findings Increased recognition of: The risks of not breastfeeding… Thior I et al, The Mashi Study, JAMA, August 16, 2006,Vol 296, No. 7 - Zidovudine plus BF or FF Formula feeding more effective in preventing postnatal HIV transmission, but BFing was associated with a lower mortality rate at 7 months. Both strategies had comparable HIV-free survival at 18 months.

HIV-associated Findings (cont’d) Fading rationale for replacement feeding… Kuhna L et al, AIDS 2005, Vol 19 No 15 No difference found in mortality 12 months after delivery with assignment to short or long breastfeeding.

HIV-associated Findings (cont’d) And possible dangers of replacement feeding… Abiona T et al. MCN, 2006, 2, pp. 135–144 Barriers to replacement feeding were: the high costs of replacement foods and fuel for cooking; an unreliable supply of electrical power; poor access to safe water and to storage facilities.

Replacement feeding is not necessarily easy or safe; It is potentially dangerous Most of the health workers had inadequate or incorrect knowledge for providing appropriate feeding counseling for HIV infected mothers As part of the PMTCT programme, all mothers had received counselling regarding safe preparation of artificial feeds and cleaning of bottles. Nonetheless, there was unacceptably high levels of contamination (38-81%) and over-dilution (14-47%)

The Dangers of Replacement Feeding are Measurable Creek T et al, Not breastfeeding, hospitalization and survival during a diarrhea outbreak in Botswana, PEPFAR 2006 Botswana: formula provided free by GoB. Not breastfeeding was associated with a 50-fold risk of emergency room visit. Not breastfeeding was associated with 8.5-fold increased risk of mortality (adjusted for SES, Age, and mother’s HIV status)

HIV and Infant Feeding: Framework for Priority Actions – Developed and Endorsed by Nine UN Agencies 1. Develop or revise (as appropriate) a comprehensive national infant and young child feeding policy, which includes HIV and infant feeding. 2. Implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions. 3. Intensify efforts to protect, promote and support appropriate infant and young child feeding practices in general, while recognizing HIV as one of a number of exceptionally difficult circumstances. 4. Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies, and to successfully carry out their infant feeding decisions. 5. Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings.

WHO Expert Meeting on HIV and Infant Feeding, October 2006 Disseminated 2007 Exclusive breastfeeding for 6 months is recommended for all women, and for HIV-infected women unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), in which case all breastfeeding should be avoided and infants should receive replacement feeding from birth. After 6 months, breastfeeding should be continued unless AFASS replacement feeding is available. Uganda

Updates on Trends, Policy, and Programs that Work

Trends: Percent of Children <6 mo old Exclusively Breastfed, ~1996 and ~ 2006 UNICEF, Trend analysis including 60% of the developing world population CBI Labbok, 2009

No lack of IYCF policies and program designs that have be shown to work Innocenti Declaration Convention on the Rights of the Child Global Strategy for Infant and Young Child Feeding HIV and Infant Feeding: Framework for Priority Actions MDGs Community-based Programs – C-IMCI Breastfeeding in emergencies

Persistent Myth: “We cannot achieve Exclusive Breastfeeding so why bother” Virtually every comprehensive or organized effort to increase exclusive breastfeeding has shown some level of success Where programmes have shared with women both the risks and benefits of exclusively breastfeeding AND have offered skilled support, EBF increases This is true in villages and cities, emergencies and established setting, in HIV pandemic areas and elsewhere…

What Works? Four Pillars Government commitment Health System -- Education of health professionals -- Quality assurance= the Ten Steps Legal protection of breastfeeding Workplace -- Paid leave and breaks -- Co-located child care 5. Demand Creation

Innocenti Declaration 1990 Four operational targets Appoint a national breastfeeding coordinator with appropriate authority, and establish a multisectoral national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations, and health professional associations Subnational Emergencies

Breastfeeding-friendly efforts On WHO Website: 2. Ensure that every facility providing maternity services fully practices all the "Ten steps to successful breastfeeding" set out in the WHO/UNICEF statement on breastfeeding and maternity services: Breastfeeding-friendly efforts On WHO Website: BFHI – new updated and expanded guidance available on line WHO Textbook Chapter

Number of hospital practices in place predicts achievement of EBF Intention Helped you get started breastfeeding when you and your baby were ready (BFHI 4) Gave you free formula samples or offers Showed you how to position your baby to limit nipple soreness (BFHI 5) Encouraged you to feed ‘‘on demand’’ (BFHI 8) Told you about community breastfeeding support resources for ongoing help (BFHI 10) Provided formula or water to supplement your breastmilk (BFHI 6) Gave your baby a pacifier (BFHI 9)

Aggressive marketing continues Result can be catastrophic 3. Give effect to the principles and aim of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions in their entirety Aggressive marketing continues Result can be catastrophic “through a Freedom of Information request at the FDA, … found algal- and fungal-based DHA/ARA have been linked to serious side effects such as virulent diarrhea and vomiting in infants consuming infant formula, many of whom required medical treatment and hospitalization.”

ILO Convention 183 and Recommendation 4. Enact imaginative legislation protecting the breastfeeding rights of working women and establish means for its enforcement ILO Convention 183 and Recommendation Art. 10.1: "A woman shall be provided with the right to one or more daily breaks or a daily reduction of hours of work to breastfeed her child". Art. 10.2: "These breaks or the reduction of daily hours of work shall be counted as working time and remunerated accordingly".

And what can be done about the base of the pillars. 5 And what can be done about the base of the pillars? 5. Demand Creation in the Community Sustainability depends on ongoing demand from the community Could be built in many countries on the Rights Framework, Convention on the Rights of the Child Article 24(2e)- “measures to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding” -Other articles are related to women in the workplace and are equally important to emphasize in the workplace in order for women to be successful at breastfeeding: -Art. 2.1: "This Convention applies to all employed women, including those in atypical forms of dependent work": (all women sharing an employment relationship with an employer, including oral contracts; therefore, self-employed women and other independent women are not included, nor, in many cases, are women working for a family enterprise; "atypical" refers to part-time work, seasonal work, etc.); -Art. 4.1: "A woman to whom this Convention applies shall be entitled to a period of maternity leave of not less than 14 weeks" (instead of 12 in Convention 103). -Art. 4.4: "Maternity leave shall include a period of six weeks compulsory leave after childbirth"; -Art. 6.3: "Where, under national law or practice, cash benefits paid with respect to leave are based on previous earnings, the amount of such benefits shall not be less than two-thirds of the woman's previous earnings"; -Art. 8.2: "A woman is guaranteed the right to return to the same position or an equivalent position at the same rate at the end of her maternity leave"

Community-Level Strategies Lay/peer counselors Women’s groups Behavior change communication Counseling by health care providers c-IMCI Baby-friendly communities Social marketing

IFE Policy basis – Operational Guidance Set of basic “dos” and “don’ts” for emergency relief staff and policy makers Key audience: all agencies working in emergency programs UN agencies NGOs, national and international donors Interagency IFE Core Group

Interagency IFE Core Group Operational Guidance 1. Endorse or Develop Policies 2. Train Staff 3. Coordinate Operations 4. Assess and Monitor 5. Implement Activities to Protect, Promote and Support Optimal Infant and Young Child Feeding 6. Minimize Risks of Artificial Feeding Interagency IFE Core Group

Infant Feeding in Emergency Guidance: Updated and ready to go Infant Feeding in Emergencies www.ennonline.net World Breastfeeding Week 2009: Be ready!

MILLENNIUM DEVELOPMENT GOALS End Poverty and Hunger Universal Education Gender Equality Child Health Maternal Health Combat HIV/AIDS Environmental Sustainability Global Partnership

Bottom line: Identify programme entry points for IYCF along the Intergenerational Lifecycle and build real protection, promotion and support into every activity COMPREHENSIVE ACTION IS NEEDED with adequate skills and knowledge Programmes for adolescents and students : Before and During Pregnancy: Child Mother Birth Maternity practices Immunisation sites, family planning clinics, other contacts

Feed the mother, breastfeed the child. Danke. Asante-sana. Tanke Feed the mother, breastfeed the child! Danke! Asante-sana! Tanke! Arigato! Ta! Obrigado! Grazie! Shieh-shieh! Gracias! Barakalo! Merci! Спасибо! Shokhrun! Shakrya! Toda-san! Thank you!!!

Major References Mezzacappa ES, Kelsey RM, Katkin ES. Breast feeding, bottle feeding, and maternal autonomic responses to stress. J Psychosom Res. 2005 Apr;58(4):351-65. Negishi H, Kishida T, Yamada H, Hirayama E, Mikuni M, Fujimoto S. Changes in uterine size after vaginal delivery and cesarean section determined by vaginal sonography in the puerperium. Arch Gynecol Obstet 1999 Nov;263(1-2):13-6 Bullough CH, Msuku RS, Karonde L. Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants Lancet 1989 Sep 2;2(8662):522-5 Edmond K, Zandoh C, Quigley M, Amenga-Etego S et al. Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality,Pediatrics 2006;117;380-386 Lancet Newborn Survival Series 2, Darmstadt G et al, Lancet 2005; 365: 977–88

Major References (continued) Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI Breastfeeding and the use of human milk. Pediatrics 2005 Feb;115(2):496-506. Labbok M, Clark D and A Goldman. Breastfeeding: maintaining an irreplaceable immunological resource, Nature Immunology. July 2004, 4(7):565-72. Labbok M. Breastfeeding: A Women’s Reproductive Right. In Keith L (ed), FIGO (International Federation of Gyn/OB) Annual Report, 2006, Int J Gynaecol Obstet. 2006 Sep;94(3):277-86 Ip S, Chung M, Raman G, ChewP, Magula N, DeVine D, Litt M, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment Number 153. 2007 April; AHRQ Publication No. 07-E007. Horta et al. WHO. Long-term effects of Breastfeeding in Developing countries. WHO Geneva, 2007 Fewtrell M. The long-term benefits of having been breast-fed. Current Paediatrics 2004.14:97-103

Major References (continued) Global Strategy for Infant and Young Child Feeding. Available at: http://www.who.int/child-adolescent-health/NUTRITION/global_strategy.htm Innocenti Declaration. Available at: http://www.unicef.org/programme/breastfeeding/innocenti.htm Innocenti Declaration 2005. Available at: http://innocenti15.net/declaration.pdf.pdf ILO Convention 183 and Recommendation 191. Available at: http://www.ibfan.org/english/news/briefing/ratifyilo00.html HIV and Infant feeding counselling: Knowledge, attitude and practice of health workers in Wesley Guild Hospital, Ilesa, Nigeria E A Adejuyigbe, A I Odebiyi MedGenMed. 2004 Jul 11;6(3):MoOrE1068 [XV International AIDS Conference, Bangkok, Thailand, July 11-16 2004] Bacterial Contamination & Over-dilution of Commercial Infant Milk in South Africa: A Sub-Study of the National Prevention of Mother-to-Child-Transmission (PMTCT) Cohort Study, Erika Bergström [XV International AIDS Conference , Bangkok, Thailand, July 11-16 2004]