1. Exclusive breastfeeding for first six months :Core Issues Planning workshop IYCF, Vietnam. 15-16 September,2003. Hanoi. Dr. Arun Gupta MD FIAP Regional coordinator IBFAN Asia Pacific, India New Delhi.

2. Greetings from India !

3. Evolution of the new recommendation on Exc. Bf. Evidence based 1993-1994 first evidence was available Took 7 years for consensus building No body knew the origin of earlier recommendation of period of exclusive breastfeeding to be 4-6 months, it was an assumption Definition was indirectly taken from the “International Code for Marketing of Breast-Milk Substitutes” which defined marketing of breastmilk substitutes.

4. Global Consensus 1994 : WABA 1994 : IBFAN 1994: UNICEF 2000: Global Technical consultation 2001: WHO Technical Review 2001: World Health Assembly adopts resolution 54.2 May 2001. 2002: Global Strategy on Infant and Young Child Feeding adopted at World Health Assembly through resolution 55.25, May 2002 and UNICEF Executive Board in September 2002. 70 Countries have adopted the policy so far.

5. WHO Expert Technical Consultations 2000 Global Technical Consultation : 28 experts recommend exclusive breastfeeding for “about six months” An external peer review 2001(March) A systematic review of current scientific evidence on the optimal duration of exclusive breastfeeding: 3000 papers, short listed, and expert group recommended “exclusive breastfeeding for 6 months, with introduction of complementary foods and continued breastfeeding thereafter”.

6. Core Issues Core Issues 1.Do we ALL know about it? 2.Is it possible to achieve? 3.What will bring a change ? 4.What is the best time for interventions?

7. 1.Do ALL know about it? Policy makers, Health professionals, care providers at all levels, Distt/Commune, families Several views of professionals Some times personal views It calls for action

8. 2. Is it possible to achieve YES Evidence from different parts of the world is available It underlines need for action in Vietnam

9. 3 months 3 months 4 months 5 months Breastfeeding counseling increases exclusive breastfeeding All differences between intervention and control groups are significant at p<0.001. Source: CAH/WHO, work in progress. References available upon request. Age: (Haider)(Albernaz)(Morrow)(Jayathilaka)(Haider) 2 wks after diarrhoeal treatment

10. Effect of breastfeeding support household visits by trained local mothers (Bangladesh) Haider R, Ashworth A, Kabir I et al. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomized, controlled trial. The Lancet 2000;356:1643-1647.

11. Effect of intervention on reported breastfeeding practices at age 3 months (India) Source: Nita B et al. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet, 361, April 2003

12. Effect of intervention on reported breastfeeding practices Duration of exclusive breastfeeding in days Source: Nita B et al. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet, 361, April 2003

13. Timely Initiation of Breastfeeding (Madagascar, Ghana, Bolivia) LINKAGES study

14. 3.What will bring a change? Behavior change

15. Behaviour change Common reasons which do not allow Exclusive breastfeeding : Not enough milk. Lack of support and information is universal To solve this problem, we need to build confidence among women This can come only through skilled counseling.

16. Behavior change Aim at behaviour change To affect the decision making of the mother or families, her motivation to overcome problems if they do come, countering negative pressures and persisting with recommended behaviour, It is important that interventions are as close as possible to desired change. To achieve so much e.g. avoid prelacteal feeds/ or water for example, provide complementary feeding at 6 months, we have to make serious efforts.

17. Behaviour change To increasing women’s confidence and motivation to sustain a behaviour, demonstration of success is important. For example : Letting her try for 2 days of exclusive breastfeeding and then see if it works, she will be much more confident to maintain that rather than asking for 6 months straight. It is the result of skillful acts Inputs are needed at services and family level

18. 4.What is the best time for interventions? 1.Intervene as close as possible to behaviour change. 2.Most beneficial for survival.

19. Protection by breastfeeding is greatest for the young infants WHO collaborative Study Team. Effects of Breastfeeding on infant and child mortality due to infectious disease in less developed countries a pooled analysis. The Lancet 2000;355:451-5

20. Protection by breastfeeding is maximum within first 2 months Relative risk of death increases with partially breastfeeding and is highest if not breastfed within first 2 months. Victora CG, Smith PG, Vaughan JP, et al. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. Lancet iii: 1987; 319-322.

21. Remember ! To be effective HOW WELL WE DO is more important than WHO does WHAT

22. Conclusions and what next ? New recommendation is scientific and accepted world over. We all should know this Finally : Transfer what we know into ACTION It is possible to achieve the set goals and has been demonstrated Skilled counseling is the answer. Act very close to desired change

23. Thank you !