2. 1 Completing the Nutrition and Health Package Dr Arun Gupta MD FIAP State Health Consultation, Bihar. 5 March 2011

3. 2 First year is critical! Malnutrition strikes the most in infancy beginning in 3-4 th month, 29-30 % 6 months. Goes up and peaks 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.

4. 3 Neonatal disorders Diarrhoea Pneumonia Source: Robert et al. LANCET 2003;361:2226-34 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

5. 4 Bihar Indicators IMR per 1000 live births (SRS Bulletin 2011) 52 Children Under 5 years who are underweight 55.9% Girl's marrying before completing 18 years 45.9% Institutional delivery 27.7% Mothers who received post-natal care within two weeks of delivery 26.2% Children 12-23 months fully immunized 41.4% Children (age 9 months and above) received at least one dose of vitamin A supplement) 49.9% Children with diarrhoea in the last 2 weeks who received ORS 22% Mothers who received post-natal care within two weeks of delivery 26.2%

6. 5 Bihar Indicators in Numbers Bihar Indicators in Numbers Population (Source- Census of India 2001) 82,998,509 Birth Rate (Source- SRS Bulletin January 2011) 28.5% Approx. No. of Children Born per Year 2,365,458 Approx. No. of Children who Die Before They are 1 123,004 Approx. No of Survivors Each Year 2,242,454 Approx. No of Survivors Under the Age 3 6,727,361 Approx. No. of Underweight Children Under the Age 3 3,760,595

7. 6 Risk of neonatal mortality according to time of initiation of breastfeeding Pediatrics 2006;117:380-386 Six times more risk of death Additional benefits

8. 7 Percentage of Neonatal Deaths (2-28 days) Saved with Early Initiation Risk of neonatal death is 4 fold, if milk based fluids or solids are given to breastfed neonates Imitation after day 1 is associated with 2.4 fold increase in risk of death PEDIATRICS 2006; 117:380-386

9. 8 1st hour initiation cuts 22% of all newborn deaths 100% 40% 10 Lac Neonatal Deaths 2.5 lac If we enhance initiation of BF within one hour 2.5 lac babies will be saved INITIATION OF BREASTFEEDING NEONATAL DEATHS SAVED Pediatrics 2006;117:380-386

10. 9 U-5 child deaths (%) saved with key interventions in India Lancet Child Survival Series,2003

11. 10 Deaths attributed to sub-optimal breastfeeding among children

12. 11 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

13. 12 Initiation of breastfeeding within one hour of birth in Bihar 0-29% scores as Red; 30-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.

14. 13 Exclusive breastfeeding in Bihar 0-11% scores as Red; 12-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.

15. 14 Gap in Feeding Practices(DLHS 3)

16. 15 Treatment of childhood diseases (DLHS-3)

17. 16 How to complete the health and Nutrition package Maternal care and nutrition Safe delivery Health check up for all ailments, newborn infections, diarrhea, ARI, fevers Immunization Growth monitoring Early breastfeeding within one hour Exclusive breastfeeding for the first six months Timely and appropriate complementary feeding after six months along with continued breastfeeding

18. 17 Core IYCF Indices Early initiation of breastfeeding within one hour Exclusive breastfeeding for the first 6 months Continued breastfeeding at 1 year Introduction of solid, semi-solid or soft foods at six months Minimum dietary diversity Minimum meal frequency Minimum acceptable diet Consumption of iron-rich or iron-fortified foods WHO, June 2010

19. 18 Enhancing optimal breastfeeding Programmatic focus on early and exclusive breastfeeding Build skilled capacity among the health workers both at block and village level Do not allow Interference of formula industry in planning and programme Ensure maternity benefits for all women

20. 19 What is special about training on IYCF

21. 20 Confidence building measures vs. Information or promotion For milk ejection 3/4

22. 21 Protecting from baby food industry

23. 22 3 main strategies Successful Breastfeeding PROMOTION Campaigns Social mobilization PROTECTION Code implementation SUPPORT Skilled support Work site support Maternity benefits

24. 23 4 support strategies Successful Breastfeeding EDUCATION & TRAINING Pre/In service School/college COORDINATION Budget Policy RESEARCH Programme and policy evaluation Implementation INFORMATION Data collection Monitoring

25. 24 Count each child who falters at the earliest

26. 25 Growth chart

27. 26 Universal Growth Monitoring Health check ups, Nutrition counselling on the way

28. 27 Exclusive Breastfeeding Phase

29. 28 Complementary Feeding Phase Faltering Dietary Recall H/O illness Recounseling Growth Monitoring

30. 29 Compliance with MGRS feeding criteria by site and overall

31. 30 WHO Growth standards How children should grow Lactation Counseling by well trained counsellors ( 5 days training ) Helping/ assistance with initiation soon after birth Preventing and resolving lactation problems. The first visit by a lactation counsellor within 24 h of delivery Subsequent visits occurred at 7, 14 and 30 d, and monthly thereafter until the sixth month.

32. 31 ‘3 in 1’ Training Programme

33. 32 What do you want to achieve? Motivation Preventing and solving the problem of ‘not enough milk’ Building confidence Maintenance of exclusive breastfeeding for the first six months Prevention of breast problems like sore nipples, mastitis ( 13% in various studies) Timely and appropriate complementary feeding after six months along with continued breastfeeding

34. 33 How we did it in Punjab 10 districts Middle level trainers : doctors and nurses Received 6 day training Imparted 3- day training to frontline workers

35. 34 Lalitpur Model Breastfeeding counselling and support services have been created for over 2 years Graduate women trained as block mentors provides supervision and training to about 3 women in each village creating a network Early breastfeeding,Exclusive breastfeeding for the first six months and complementary feeding all have shown improvement significantly.

36. 35 Infant and young child feeding practices before and after intervention in Lalitpur District (600 villages)

37. 36 MEP..the minimum essential programme of services in NRHM Nutrition support to mothers, maternity benefits,IGMSY, Family counsellors IYCF by a 3 day training, at birth assistance, home visits 4 in 2 weeks, and then every 2 weeks for 2 months, and every month till 12 months Family Cluster of 5-10 Block/PHC District level and above, medical colleges. Block Mentors of IYCF, act as trainers, supervisors, support on difficult problems in Breastfeeding like not enough milk, engorgement, mastitis etc. SPECIALIST COUNSELLOR on IYCF SPECIALIST COUNSELLOR on IYCF IN ALL PUBLIC AND PRIVATE HOSPS

38. 37 Thanks !