Evidence for infant and young child survival Dr Arun Gupta MD FIAP

Overview State of Child Nutrition and Survival India and AP. Evidence for infant and young child survival State of breastfeeding/IYCF practices in India and AP What can be done to enhance breastfeeding rates? How can we do it?

First year is critical! Malnutrition strikes the most in infancy beginning in 3-4 th month, % at 6 months, goes up and peaks about 46% by 18 months, flat curve after that (NFHS 3). Years of life Brain development Underweight (-2sd) NFHS-3 Over 60 million 10 lakh children die during first month, 14 lakhs by 1 year, and 20 lakhs by 5 yrs. 2/3rd are related to poor feeding.

The AP Report Card on Infant health IndiaA.P.Source Initiation of Breastfeeding within 1 hour40.5%47.8%DLHS-3 Exclusive Breastfeeding (0-6 months)46.8%43.9%DLHS-3 Complementary Feeding (6-9 months)57.1%55%DLHS-3 ORS Given to Children with Diarrhoea34.2%43.3%DLHS-3 Children months fully immunized (BCG, measles and 3 doses each of polio/DPT) 54.%67.1%DLHS-3 Infant Mortality Rate (IMR) per 1000 live Births 5352SRS Bulletin 2009 Children Under 3 Years Who are Underweight 32.5%42.5%NFHS-3 Children (age 9 months and above) received at least one dose of vitamin A supplement) 54.5%78.8%DLHS-3

Estimated Number of Babies Who Die Every Year India 14 Lakhs Under 1 yr. 20 Lakhs Under five yrs. Andhra Pradesh. 1 lakh under one year

Numbers….in AP Population : 8.2 Crore Number of children born : Lakhs Number of underweight under 3: 22.7 Lakhs

IMR

Neonatal disorders Diarrhoea Pneumonia Source: Robert et al. LANCET 2003;361: Three Major Killers 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 MOSTLY PREVENTABLE

U-5 child deaths (%) saved by universlising key interventions in India Lancet Child Survival Series,2003

Deaths attributed to sub-optimal breastfeeding among children

EBFEBF Relative risk associated with child feeding practices compared with Partial breastfeeding (LSMCU 2008)

Infection specific : Neonatal Mortality Risk by early infant feeding practices Source: Edmond KM et al. Am J Clin Nutr :

Long term Impact of BREASTFEEDING Subjects who were breastfed experienced lower mean blood pressure and total cholesterol, as well as higher performance in intelligence tests. Prevalence of overweight/obesity and type-2 diabetes was lower among breastfed subjects. WHO, 2007

Optimal Infant and Young Child Feeding Starting breastfeeding within one hour of birth Exclusive breastfeeding for the first six months Introducing appropriate and adequate complementary feeding after 6 months along with Continued breastfeeding for two years or beyond WHO: 2/3rd of all under five deaths are related to POOR FEEDING.

Feeding Practices NFHS 3 (First Year)

Trends in 3 indicators

State of IYCF in AP And Some other indicators

Feeding practices in AP and neighbors

Initiation of breastfeeding within one hour of birth - District wise in AP( DLHS 3) 0-29% scores as Red; 30-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.

Exclusive breastfeeding in first six months - District wise in AP( DLHS 3) 0-11% scores as Red; 12-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.

NFHS 3 : AP Some other indicators

How many women know about family planning?

High-risk births have higher mortality rates

Full Immunization Coverage by State Percentage of children months

Trends in Vaccination Coverage Percentage of children months receiving vaccinations

How many children receive anganwadi centre services? Percentage of age-eligible children in areas covered by an anganwadi centre receiving services

What Can We Do to Change ?

PM’s Council on India’s Nutrition Challenges decided on 24 Nov 2010 “..The ICDS requires strengthening and restructuring. “..with special focus on pregnant and lactating mothers and children under three.” A nationwide campaign to educate people “…. against malnutrition so as to address issues of status of women, the care of pregnant mothers and children under two, breastfeeding, and the importance of balanced nutrition, health, hygiene and sanitation….”

Some basics…. Universalisation of reach to under two: Food, including for infants, breastfeeding, services and Care. For enhancing exclusive breastfeeding for the first six months mothers and babies MUST stay together, rest, food, stay at home..time for caring their baby. For this we must have maternity benefits, women have to go to work ( IGMSY Scheme is one such action Two districts from AP West Gadavrai, and Nalgonda are included ) Skilled support in health systems or at home “Not enough milk” is a universal feeling among women which can be improved if we could build their confidence…this can be solved by “counselling” Strict enforcement of the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992, and Amendment Act 2003.) Recent letter from MOH and WCD is an example to follow up. No sponsorships of doctors by baby food companies or their related front organisations.

Enhancing breastfeeding rates ? Taking action in at least 10 areas Policy coordination, making work IMS Act, accurate information, health care system support, outreach to all families, setting right medical curriculum, maternity entitlements, support to women during HIV and emergency situations, monitoring and evaluation….the 33 country report shows gaps in all of them.

EPW Sept.2007

Evidence on What Works? Lancet 2008 Analysis of global evidence For EX.BREASTFEEDING : One to one or group counselling works for enhancing exclusive breastfeeding rates For COMPLEMENTARY FEEDING : Education and counselling on complementary feeding in food secure homes, PLUS food supplements in food insecure homes

The Critical hormone link to breastfeeding For milk ejection

Cochrane review on Support for breastfeeding mothers Britton C et al. Cochrane Database of Systematic Reviews 2006, Issue trials (29,385 mother-infant pairs) from 14 countries Additional lay support was effective in prolonging exclusive breastfeeding WHO UNICEF training was effective in prolonging Exclusive breastfeeding

The impact of community interventions: Improving infant feeding in rural Haryana, India The impact of community interventions: Improving infant feeding in rural Haryana, India through multiple contacts is feasible and improves uptake of other child health interventions. Health policy and Planning 2005; 20(5):

What BPNI has done on this 19 years of experience in supporting governments with planning, advocacy, monitoring the IMS Act, state capacity building etc. Developed ‘3 in 1’ Infant and Young Child feeding Counselling A training programme, (Integrated breastfeeding, complementary feeding and infant feeding & HIV counselling) based on WHO UNICEF’s 3 courses. Tried in Lalitpur in UP as district level intervention Working with Haryana, Uttrakhand, AP, Punjab, and Bihar

Infant and young child feeding practices before and after intervention in Lalitpur District (600 villages)

Recommendations Work on recommendations of the PM’s Council on India’s Nutrition Challenges Home visiting for under 2s as a policy : Ensure universal coverage of key interventions including early initiation of breastfeeding, exclusive breastfeeding for the first six months, timely and appropriate complementary feeding after six months along with continued breastfeeding for two years. Put up additional women workers as Nutrition counsellors at village level and mentors at block level Link with growth monitoring of each child. Ensure universal coverage of ORS and immunization. Ensure universal coverage of maternity benefits. Training of all workers must include skills on Breastfeeding IYCF, at least 3 day training for IYCF counsellors and 7 day for IYCF consultants. IMS Act be effectively implemented. Nutrition programmes should be free from conflicts of interests.