Regional Consultation Meet on Nutrition Bhubhneshwar Importance of Breastfeeding for Child Survival , Development and Health Regional Consultation Meet on Nutrition Bhubhneshwar 18-19 July 2005 Dr.Arun Gupta MD FIAP National coordinator BPNI BP-33, Pitampura, Delhi 110 088 arun@ibfan-asiapacific.org

Three Major Killers in India Neonatal sepsis Diarrhoea Pneumonia Source: Robert et al. LANCET 2003;361:2226-34

Neonatal sepsis Breastfeeding is the No. 1 preventive intervention compared to any other intervention Lancet Series on child survival, and now on newborn survival : 2003 and 2004 Definition of Breastfeeding : Exclusive breastfeeding for the first six months and continued breastfeeding for next six months

Diarrhea Breastfeeding is the No. 1 preventive intervention compared to any other intervention Lancet Series on child survival, and now on newborn survival : 2003 and 2004 Definition of Breastfeeding : Exclusive breastfeeding for the first six months and continued breastfeeding for next six months

Pneumonia Breastfeeding is the No. 1 preventive intervention compared to any other intervention Lancet Series on child survival, and now on newborn survival : 2003 and 2004 Definition of Breastfeeding : Exclusive breastfeeding for the first six months and continued breastfeeding for next six months

Look at other interventions Under-5 deaths preventable through universal coverage with individual interventions Look at other interventions Source: Jones et al. LANCET 2003;362:65-71

10th Five year Plan GOALS

Trends in Infant Feeding Practices 1992 1999 (NFHS-1) (NFHS-2)

Exclusive breastfeeding falls rapidly from first month onwards (NFHS-2-1999) Target line Achieved

The deficit to Make up!

It enhances brain development Brain develops in first two years the most Breastfeeding contributes to IQ, visual acuity, mathematical abilities and analytical capacity. ( evidence available) Prepares children for BETTER LEARNING at PSE/Schools What ever level of survival we achieve, we will always achieve higher level of child development: sustainable human development

Exclusive breastfeeding Prevents HIV in infants Early Exclusive Breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005 19:699-708

It prevents Obesity Sufficient evidence available that BREASTFEEDING/ExBF prevents childhood obesity 15% urban populations are projected to be obese American Academy of Pediatrics guidelines: rate Breastfeeding as number one preventive intervention along with decreased TV viewing Treatment costs are horrible and unaffordable even by USA

It has Huge economic value Market Value of breastmilk : difficult to put a cost ! Artificial feeding you have to spend about RRs 450 per day to feed a 3 months old infant, perpetuates income poverty by additional spending on milk and sickness In the Milk banks of Norway it is available at 50 $ per liter as compared to the cost of powder milk formula of about 2-3 $ per day. At Current level of production of breastmilk in India : 4000 million liters If we achieve national goals : 6500 million liters Economic worth $ 326 billion

10th Five Year Plan Goals Exclusive Breastfeeding 0-6 months Note: NFHS 2 data for exclusive breastfeeding 0-3 months and 10th Plan Goals data is 0-6 months

Exclusive Breastfeeding 4 states (BPNI Data 2003)

When malnutrition strikes…Under three First three years are for ever….. NFHS-2, 1998-99

(IMR and Underweight U-3) IMR (MOHFW, 2001) Under-weight children (NFHS-2)

Exclusive breastfeeding prevents child malnutrition Strikes Where it begins in early child hood 0-6 months is critical, 6-12 is next We allow child undernutrition to set in With poor feeding( BREASTFEEDING and COMPLEMENTARY FEEDING ) Neonatal infections, Diarrhea, pneumonia, 2/3 mortality is in 1st year According to WHO, 2/3rd mortality is related to poor feeding practices

Can we save babies? YES Make IYCF widely available Prevent malnutrition in children

What works ? Behavior change and timing is critical Intervention must be as close to desired change Requires Skillful acts not as we deliver a vaccine

Experience from Bihar villages 20-80% mothers in rural area start some supplements within first 2 months. Most mothers do so because they feel “not enough milk” None of the ANMs in PHC could provide correct answer to what should be done, neither an AWW ( one of whom was MSc Home Science) HWs and RMPs provide “top milk feeds as advice” Commercial promotion makes formula and bottle use as common Open your presentation with an attention-getting incident. Choose an incident your audience relates to. The incidence is the evidence that supports the action and proves the benefit. Beginning with a motivational incident prepares your audience for the action step that follows.

Summary findings of a qualitative study from 49 districts(98 blocks) BPNI, India 2003 Inadequate knowledge in the community as well as in the healthcare system. Lack of access to skilled counselling and practical support by health care workers Traditional practices. Lead to pre-lacteal feeding Separation of mother and baby immediately after delivery continues. (in private sector) Families and mothers believe that mothers don’t have enough milk. Long working hours in offices and in the field Confusing/conflicting messages by health functionaries

What ICDS offers? Women workers : AWWs and helpers Context is “food” for poor or malnourished, SNP and PSE as core interventions Food based interventions tackling “HUNGER” And for the younger ones it is not an issue

What is left out ? Lack of understanding what are determinants of child malnutrition For the 0-6 months it is Exclusive breastfeeding and 7-24 months continued BREASTFEEDING with adequate complementary feeding ICDS’s position as true child development programme Nutrition and health education : weakest and IYCF is missing; skills on IYCF counseling for motivation of mothers are non existent .

REPOSITION ICDS Outcome should be “Smart kids” Healthy kids Smiling kids Smart ADULTS Smart SOCIETY

What makes women successful in BF Practical help and support from all quarters especially health care providers. Good accurate information and timely counseling Building confidence when they have a ‘feeling’ of not enough milk, Assistance To initiate breastfeeding within one hour, Assistance in proper sucking position to allow effective and frequent sucking and thus optimal milk transfer; Prevent breast problems like sore nipples and engorgement, Solve problems if they do arise, Answer any questions if mothers may have, Counseling on adequate and appropriate complementary feeding, Counseling on HIV and Breastfeeding for infant feeding options and support to their choice.

ACTION:Make breastfeeding support visible more widely available Making breastmilk more widely available Mother support networks Breastfeeding support centers;(this is not another building) Successful women offering help Redefine the role of workers specifically holding AW responsible for under three nutrition and IYCF counseling as service in DWCD organogram

Integrate IYCF effectively In outreach programmes What does that mean? Strengthening of Pre-service 7 days training on Breastfeeding, complementary feeding, and HIV for ALL health professionals 3- days training for frontline workers (We have done this for NACO recently) putting infant feeing in the counselors training, other departments also needed to do similar exercise) In service : Additional skills training is necessary

Put effective monitoring in place Exclusive breastfeeding 0-6 months as lead proxy indicator of progress With its allocations With a Context With an accountability mechanism REPORT it annually

What health systems offers? So far relied on pieces of occasional information not on education which requires skills Inadequately equipped with skills Less supportive of breastfeeding HWs and doctors believe they know enough Encourage adoption of artificial feeding for no fault of women

What Health should do? Implement the “Investing in Development” A Practical Plan to Achieve the MDGs: Report to the UN Secretary General Millennium Project NY 2005” and offer “Neonatal Integrated Package” that includes, breastfeeding education including for HIV positive mothers. Provide continuing education services to ICDS Cant wait for IMNCI to be available universally Newborn care and BREASTFEEDING must be universalized now

I& Y C F Counseling: A Training Course Course- Structure (Algorithm) I& Y C F Counseling: A Training Course The 3 in 1 course SKILLS Director Preparation of trainers (learning training skills 1wk) Learning through conducting training using module 1wk Trainer + Co-trainer Training of trainers FLW 1wk Training of FLW 3days

Can we do all this without costs? This is what is we need to do differently Reorganize resources for Care under one including maternal nutrition and care 10th Plan notes that improving infant feeding does not require additional spending. This thinking needs to change! Ensuring this Free fluid costs! Not delivered as vaccines but does much more than that Requires as much spending

What other states are doing in collaboration with BPNI? UP: training of ALL frontline workers in 8 districts ( Sitapur has begun) Uttranchal : 13 district study on INFANT AND YOUNG CHILD FEEDING and FU with a state plan in one year. Haryana : In its State allocation, budgeted on improving infant and young child feeding and got it Training initiatives started in MP, Bihar, Rajasthan (Govt-BPNI-UNICEF) Pondicherry, AP, Punjab: Initial enquiries with us

INVEST WISELY ! Put budget lines for IYCF action plans with annual monitoring in relation to development At least match with vaccination programmes 11th plan is at arms length !

Reorganize resources, each step requires allocation Prenatal- 0-6 months 6 m-3 yrs 3 -6 yrs. CARE : Skills training and Counseling, care of women HEALTH Immunization etc FOOD SUUPLY for Hunger/ PSE

National guidelines on IYCF launched 6 August, 2004

The law to protect, promote and support breastfeeding: 6 August,2004

Beginning of the rise of breastfeeding ! Be a part of history !! Thanks !