Dr Yasmeen Memon Associate Professor Paediatric Unit 1 LUMHS IYCF Dr Yasmeen Memon Associate Professor Paediatric Unit 1 LUMHS

What do these letters stand for? I Y C F = Infant (0—11 months) = Young ( up to 2 years) = Child = Feeding

The Global Strategy for Infant and Young Child Feeding(IYCF) Developed by WHO and UNICEF to revitalize world attention on the impact that feeding practices have on infants and young children. Malnutrition has been responsible, directly or indirectly, for over 50% of the 10.9 million deaths annually among children <5 years. Over two-thirds of these deaths occur in the first year of life

Major Causes of Death Among Children under five in developing countries, 2008 Deaths associated With malnutrition 54% Source: The World Health Report 2008, WHO, Geneva.

Global situation (save the children-2012 report) 7.6 million children U5 yr die /year 2.6 million (35%) ---- malnutrition---1/3rd (10%) of these deaths are due to micronutrient deficiencies 170 million (27% of all children globally )--- stunted ( low Ht/age), 100 million of total in Asia 100 million --- under weight (Low wt/age)---19% of child death 60 million ---wasted (low wt/ht) 20 million/yr ---LBW (<2.5 kg)

The State of the World’s Children 2014 More than 150 million children in developing countries are malnourished. According to more recent estimates, IUGR, stunting and severe wasting are responsible for one third of under-5 mortality.

Nutrition and life course

Malnutrition in Pakistan (NNS 2011) In Pakistan, the nutritional status of children under five years of age is extremely poor Child Malnutrition rates in Pakistan is significantly high. Types of Malnutrition PDHS 2012-13 Stunting(low Ht/age) 43.7% ( Sind -49.8%) 45% (57% in sind ) Under weight ( low wt/age)-- 31.5%( Sind 39.8%) 30% Wasting (low wt/Ht) - 15.1%(Sind 17.5%) 11% (17.5% in sind ) Micronutrient deficiency---- Anemia --- 61.9% ( Sind 73%) Vitamin A deficiency --- 54% (Sind 53%) Vitamin D deficiency --- 40% (Sind 43%) Zinc deficiency --- 37% (Sind 39.2%)

Trend of IYCF in Pakistan (preliminary results) DHS 2006-07 DHS 2012-13 (preliminary results) Exclusive breastfeeding 37.1% 37.7% Predominant breastfeeding 18.2% 17.1% Bottle feeding 32.1% 41.0% Complementary feeding Recommended CF practices 33.6% 56.6% 15%

IYCF Component Nutrition of pregnant & Lactating women's Breast feeding Complementary feeding Counselling & Key messages .

Appropriate diet during pregnancy & lactation During Lactation 3 meals each day plus two extra small meals or snacks in between meals to sustain energy and better take care of child Peas, lentils , beans, oil, green vegetables or fruit and meat Never stay thirsty; use of juice, soups etc. should be increased During Pregnancy Women does not need more food during pregnancy 3 meals each day plus one extra small meal or snack in between meals

Advantages of breast feeding Breast milk • Breastfeeding immediately after birth helps: - Reduce bleeding after delivery - Quicken the expulsion of placenta Helps emotional bonding and development Helps delay a new pregnancy• Exclusive breastfeeding – contraception (98% effective) Protects mothers’ health • Reduces risks of breast and ovarian cancer. Benefits of Breastfeeding for the community ---Better brain development - leads to intelligence and better jobs • Healthy children become healthy adults that can work hard Perfect nutrients Easily digested; efficiently used Protects against infection It is free! Costs less than artificial feeding Breastfed children get sick less often

TEN STEPS TO SUCCESSFUL BREASTFEEDING The Baby-Friendly Way TEN STEPS TO SUCCESSFUL BREASTFEEDING Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within an half hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk unless medically indicated. 7. Practise rooming in – allow mothers and infants to remain together – 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. 14

During first 6 months = = + + +

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28/2 Key Message 1 Breastfeeding for two years or longer helps a child to develop and grow strong and healthy

Good and poor attachment 3/8 Good and poor attachment What differences do you see? 1 2

Good position & Attachment Baby head & body in line Baby held close to mothers body Baby whole body supported Baby approaches breast nose to nipple. More areola visible above baby’s mouth than below Baby’s mouth wide open Lower lip turned outwards Chin close to breast

Rider’s position

Energy required by age and the amount supplied from breast milk 28/4 Energy required by age and the amount supplied from breast milk Energy (kcal/day) 1000 800 0-2 m 3-5 m Age (months) Energy Gap Energy from breast milk 6-8 m 9-11 m 12-23 m 600 400 200

Complementary food Complementary feeding means giving other foods in addition to breast milk. These other foods are called complementary foods Complementary foods should be introduced from 6 months of age, when breast milk alone no longer meets infant’s nutrient needs. According to age of the child food needs to have the right amount, texture, variety, and should be given in the right frequency and cleanly prepared. FATVAH ---frequency, amount, texture, variety, active feeding, hygiene

Breast milk in second year of life 2/11 Breast milk in second year of life 100% Gap 75% Percentage of daily needs 50% Provided by 550 ml breast milk 25% 0% Energy Protein Iron Vitamin A Nutrient

Key Message 2 28/5 Starting other foods in addition to breast milk at 6 completed months helps a child to grow well

29/5 Key Message 3 Foods that are thick enough to stay in the spoon give more energy to the child Just right Too thin

Gap for iron Absorbed iron needed and amount provided 30/2 Gap for iron Absorbed iron needed and amount provided 1.2 0.8 0.4 Iron gap Iron from birth stores Iron from breast milk 0-2 m 3-6 m 6-8 m 9-11 m 12-23 m Age (months) Absorbed iron (mg/day)

Animal-source foods are especially good for children, to help them grow strong and lively 30/3 Key Message 4 yoghurt poultry fish meat cheese eggs liver

30/4 Key Message 5 Peas, beans, lentils, nuts and seeds are also good for children lentils beans peas nuts seeds Groundnut paste

Vitamin A needed and amount provided 30/5 Gap for vitamin A Vitamin A needed and amount provided 400 Vitamin A gap Vitamin A from birth stores Vitamin A from breast milk 0-2 m 3-6 m 6-8 m 9-11 m 12-23 m Age (months) Vitamin A (µg RE/day) 300 200 100

30/6 Key Message 6 Dark-green leaves and yellow-coloured fruits and vegetables help a child to have healthy eyes and fewer infections pumpkin spinach papaya mango carrot yellow sweet potato

Gaps to be filled by complementary foods for a 12-23 months old child 31/2 Gaps to be filled by complementary foods for a 12-23 months old child

Three meals 31/3 Nutrients from meals Mid-day meal Gap Morning meal Evening meal Breast milk

Three meals and two snacks 31/5 Snacks Mid-day meal Gap Morning meal Nutrients from meals Evening meal Breast milk

Key Message 7 A growing child 6 – 8 months needs 2 – 3 meals a day 31/6 A growing child 6 – 8 months needs 2 – 3 meals a day A growing child 9 – 24 months needs three to four meals a day Plus additional 1 – 2 snacks if the child is hungry: Give a variety of foods

31/9 Key Message 8 A growing child needs increasing amounts of food

34/3 Key Message 9 A young child needs to learn to eat: encourage and give help … with lots of patience

37/3 Key Message 10 Encourage children to drink and eat during illness and provide extra food after illness to help them recover quickly

From 6 up to 9 months ( FATVAH) x

From 9 up to 12 months ( FATVAH) x

From 12 up to 24 months ( FATVAH) x

3 step counseling Help you to counsel with mothers for infant & young child feeding Step 1 ---- Assess ; Ask , Listen & observe--- Assess age appropriate feeding practices & health of child & mother Step 2 ---- Analyze ; identify difficulties & prioritize the difficulties if more then than 1 difficulty, praise mother Step 3 ---- Act ; discuss , suggest small amount of relevant information, give option regarding feeding difficulty & help mother to select one option . Additional Support --- Refer to health facility, IYCF support group in community, Health worker Thank the mother ,Set next meeting for F/up

Benefit of IYCF teaching/training Improvement in feeding practices ↓ Prevention of malnutrition & its consequences ↓ U5 mortality → Achieve MDG 4 Healthy children → Healthy adult work hard improve GDP National benefit Benefit to community Helpful for onward counseling and support to mothers to carry out recommended feeding practices for their infants and young children from birth up to 24 months of age at any opportunity.

THANK YOU

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