Nutrition And The 0 6 Months Infants (Final)


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  • Source: Table 4.10
  • The United Nations Millennium Declaration, was adopted on 8 September 2000 by all 189 Member States of the United Nations (147 of them represented directly by their head of State or Government). This Declaration embodies a large number of specific commitments aimed at improving the lot of humanity in the new century. The Declaration is divided into eight sections as listed in the slide. Sections 3 and 4 are highlighted since these are the only sections within the Declaration from which the Millennium Development goals have grown.
  • A vast scientific literature exists demonstrating the health, psychosocial, and economic benefits associated with breastfeeding & different BF patterns. A 2000 meta-analysis of over 500 infant deaths in environments where diarrhea and respiratory infections are the major causes of infant mortality ( Brazil, Pakistan, the Philippines – …data from the Gambia, Ghana and Senegal after 11 mo because virtually all babies were BF in first year ) found that non-breastfed babies were significantly more likely to die of infectious diseases than breastfed infants (WHO, 2000). The benefits of breastfeeding were greatest in the first two months of life (OR 5.8) and declined with age (up to the first year, at which time it did not continue to show continued declines - hovered around 2 (12-15 mo  1.6, 16-19 mo  2.1, 12-23 mo   1.7) . The Risk of death from not BF in settings with HIV may be higher than these WHO, 2000 overall figures because: - differential risks in WHO 2000 by education of mother at 6-11 mo: OR = 5.1, lowest tercile (least education, authors’ rec for HIV) (vs 2.0 medium tercile or 1.1 highest tercile) r ather than pooled OR of 1.8 (6-8 mo) or 1.4 (9-11) - Non – BF infants 12-24 mo of age in Ghana had 7.9 times higher risk of death than BF infants. Two more studies since this meta-analysis have also confirmed higher rates associated with not-BF - Bahl et al* found the ROR was 10.5 from 6 wk to 6 mo in Ghana, India and Peru - Rutstein**(DHS) estimated ROR was about 3 ( 2.7) for 6-12 months *Bahl R, et al. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bull World Health Organ. 2005 Jun;83(6):418-26. **Rutstein SO Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: evidence from the DHS. Int J Gynaecol Obstet. 2005 Apr, 89 Suppl 1:S7-24.
  • Nutrition And The 0 6 Months Infants (Final)

    1. 1. Dr. K P Kushwaha Prof & Head, BRD Medical College, Gorakhpur Nutrition and the 0-6 Months Infants
    2. 2. Evidence classification <ul><li>Evidence class </li></ul><ul><li>Class I </li></ul><ul><li>Class II </li></ul><ul><li>Class III </li></ul><ul><li>Criteria for evidence </li></ul><ul><li>Randomized control trial ;at least one </li></ul><ul><li>Well organized control trials without randomization, cohort or case control ,cross sectional, retrospective ;more than one </li></ul><ul><li>Case reports, reports of expert comittees, guidelines, </li></ul>
    3. 3. Infant feeding Recommendations (Global strategies for Infant & Young Child Feeding) <ul><li>Exclusive breastfeeding form birth to 6 months </li></ul><ul><li>Appropriate complementary feeding after 6 months + Breastfeeding </li></ul><ul><li>Sustaining breastfeeding for 2 years and beyond </li></ul><ul><li>Related maternal, nutrition & care </li></ul><ul><li>Building community support and health system support protecting infant feeding practices from commercial influences </li></ul>Slide
    4. 4. Infant feeding Recommendations (Global strategies for Infant & Young Child Feeding) <ul><li>Preterm, ELBW, VLBW and above 1600gm. All need breastmilk. </li></ul><ul><li>Feeding method and approaches are varied. </li></ul>Slide
    5. 5. HIV :2000 and 2006 WHO Recommendations <ul><li>Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time. </li></ul><ul><li>When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected women is recommended </li></ul><ul><li>When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. </li></ul><ul><li>Otherwise, exclusive breastfeeding is recommended during the first months of life. </li></ul>Slide
    6. 6. IYCF Practices-India <ul><li>Initiation with in 1 Hr </li></ul><ul><li>Exclusive Breastfeeding </li></ul><ul><li>Timely (appropriate ?) complement </li></ul><ul><li>Sustained breastfeeding 2 years and beyond </li></ul><ul><li>23.4 </li></ul><ul><li>46.3 </li></ul><ul><li>55.8 </li></ul><ul><li>38.4 </li></ul>Source: NHFS-3 Slide ( Squeezing and discarding of colostrum and prelacteal feeds are quite common)
    7. 7. Trends in Nutritional Status Percent of children age under 3 years (Low-height-for-age) (Low-weight-for-height) (Low-weight-for- age) Slide Source: NHFS-2 & 3
    8. 8. Anaemia among Children Percent of children 6-35 months with anaemia Slide
    9. 9. How Many Children Receive Services from an AWC? ICDS (??? 0 – 6 yrs ) Percent of age-eligible children in areas with an AWC Slide How many 0-6 ms are being looked after? Source: NHFS-3
    10. 10. Benefits to Baby (evidence class I –III) <ul><li>Optimum growth </li></ul><ul><li>Brain growth </li></ul><ul><li>Reduce risk for: </li></ul><ul><ul><li>Undernutrition </li></ul></ul><ul><ul><li>Upper and lower respiratory infections </li></ul></ul><ul><ul><li>Otitis media (ear infections) </li></ul></ul><ul><ul><li>Urinary tracts </li></ul></ul><ul><ul><li>Sytemic Infections </li></ul></ul><ul><ul><li>Gastroenteritis </li></ul></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Overweight/obesity </li></ul></ul><ul><ul><li>SIDS </li></ul></ul>Slide
    11. 11. Why Breast milk for preterm <ul><li>To Protect </li></ul><ul><ul><ul><li>Infections </li></ul></ul></ul><ul><ul><ul><li>NEC </li></ul></ul></ul><ul><li>To Provide </li></ul><ul><ul><ul><li>PUFA, growth factors, hormone, tropic factors </li></ul></ul></ul><ul><ul><ul><li>Better visual and cognitive development </li></ul></ul></ul><ul><li>To Involve mother in care, including KMC </li></ul><ul><li>To Provide nutrition's with high bio availability </li></ul>Slide Evidence class I
    12. 12. Lancet 2004;363:1571-8 Singhal A, Cole TJ, Lucas A Breastmilk and Lipoprotein profile in adolescents born preterm: Followup of a prospective randomised study (n=926) Slide Evidence class I
    13. 13. Breast milk composition differences (dynamic) <ul><li>Gestational age at birth (preterm and full term) </li></ul><ul><li>Stage of lactation (colustrum and mature milk) </li></ul><ul><li>During a feed (foremilk and hindmilk) </li></ul>Slide Evidence class I
    14. 14. Slide
    15. 15. Slide
    16. 16. Colostrum ( evidence class I-III ) <ul><li>Property </li></ul><ul><li>Antibody-rich </li></ul><ul><li>Many white cells </li></ul><ul><li>Purgative </li></ul><ul><li>Growth factors </li></ul><ul><li>Vitamin-A rich </li></ul><ul><li>Importance </li></ul><ul><li>protects against infection and allergy </li></ul><ul><li>protects against infection </li></ul><ul><li>clears meconium; helps prevent jaundice </li></ul><ul><li>helps intestine mature; prevents allergy, intolerance </li></ul><ul><li>reduces severity of some infection (such as measles and diarrhoea); prevents vitamin A-related eye diseases </li></ul>Slide
    17. 17. Slide
    18. 18. More Benefits to Baby (When they grow) <ul><li>Reduced risk for: </li></ul><ul><li>- Dental disorders </li></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Crohn’s disease </li></ul></ul><ul><ul><li>Childhood Leukemia </li></ul></ul><ul><ul><li>Cardiovascular disease </li></ul></ul><ul><ul><li>Celiac disease </li></ul></ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul>Slide Evidence class II -III
    19. 19. Benefices for Mom <ul><li>Rapid recovery after having a baby </li></ul><ul><li>Decreases risk of anemia </li></ul><ul><li>Weight reduction </li></ul><ul><li>Reduces risk of breast cancer </li></ul><ul><li>Reduces risk of ovarian cancer </li></ul><ul><li>May reduce risk of endometrial cancer </li></ul><ul><li>Reduces risk for osteoporosis </li></ul><ul><li>Delays next pregnancy </li></ul>Slide Evidence class II -III
    20. 20. Community Benefits New parents miss Less work Fewer healthcare Visits & lower Treatment costs Breast milk is a Natural and Renewable resource Slide Evidence class III
    21. 21. Breastfeeding prevents under nutrition and obesity <ul><li>Under nutrition 40-50% </li></ul><ul><li>Obesity 50% </li></ul><ul><li>Evidence class II-III </li></ul>
    22. 22. Breastfeeding decreases the prevalence of obesity in childhood at age five and six years, Germany Adapted from: von Kries R, Koletzko B, Sauerwald T et al. Breast feeding and obesity: cross sectional study. BMJ, 1999, 319:147-150. Slide
    23. 23. Higher Intelligence quotient ( Evidence class I-II) BF = breastfed FF = formula fed BM = breast milk Slide BF 2.1 points higher than FF Study in 6 months to 2 year- olds 1988 BF 8.3 points higher than FF Study in 7.5-8 year-olds 1992 BF 2 points higher than FF Study in 3-7 year-olds 1982 BM 7.5 points higher than no BM Study in 7.5-8 year-olds 1992 BF 12.9 points higher than FF Study in 9.5 year-olds 1996 References: <ul><li>Fergusson DM et al. Soc </li></ul>SciMed 1982 <ul><li>Morrow-Tlucak M et al. </li></ul>SocSciMed 1988 <ul><li>Lucas A et al. Lancet 1992 </li></ul><ul><li>Riva Eet al. Acta Paediatr 1996 </li></ul>
    24. 24. Potential Child Mortality Reduction from Preventive Interventions Jones et al. How many deaths can we prevent this year? Lancet 2003 Slide Preventive Intervention Number (thousands) Deaths prevented as proportion of all child deaths Breastfeeding 1301 13% Insecticide - treated materials 691 7% Complementary feeding 587 6% Zinc 459 5% H influenzae vaccine 403 4% Antiseptic delivery 411 4% Water, sanitation, hygiene 326 3%
    25. 25. The value of breast milk to the national economy in India <ul><li>National production of breast milk by all mothers in India for the children they were breastfeeding at the time of the estimate was about 3944 million liters over 2 yrs. </li></ul><ul><li>If the breast milk produced were replaced by tinned milk, it would cost 118 billion Rupees. </li></ul><ul><li>If imported, the breast-milk substitutes would cost 4.7 million USD. </li></ul><ul><li>If breastfeeding practices were optimal, breast milk production would be twice the current amount, doubling the savings by fully utilizing this “national resource”. </li></ul>Adapted from: Gupta and Khanna. Economic value of breastfeeding in India. The National Medical Journal of India, 1999, May-June 12(3):123-7. Slide
    26. 26. Comparative health care costs of treating breastfed and formula-fed babies in the first year of life in a health maintenance organization (HMO) <ul><li>When comparing health statistics for 1000 never breastfed infants with 1000 infants exclusively breastfed for at least 3 months, the never breastfed infants had: </li></ul><ul><li>60 more lower respiratory tract illnesses </li></ul><ul><li>580 more episodes of otitis media, and </li></ul><ul><li>1053 more episodes of gastrointestinal illnesses </li></ul>Adapted from: Ball & Wright. Health care costs of formula-feeding in the first year of life. Pediatrics, 1999, April, 103(4 Pt 2):870-6. Slide
    27. 27. In addition, the 1000 never-breastfed infants had: <ul><li>2033 excess office visits </li></ul><ul><li>212 excess hospitalizations </li></ul><ul><li>609 excess prescriptions </li></ul><ul><li>These additional health care services </li></ul><ul><li>cost the managed care system </li></ul><ul><li>between $331 and $475 per never-breastfed infant </li></ul><ul><li>during the first year of life. </li></ul>Adapted from: Ball & Wright. Health care costs of formula-feeding in the first year of life. Pediatrics, 1999, April, 103(4 Pt 2):870-6. Slide
    28. 28. Slide
    29. 29. What is the infant mortality risk from not breastfeeding? WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000 Feb 5;355(9202):451-5. Pooled Odds Ratios Lowest tercile of mat. education Ghana Slide
    30. 30. The baby Killer <ul><li>Sale of formula in India Rs </li></ul><ul><li>Sale of Bottles in India Rs </li></ul>(Andy Chetley/war on want, 1974) Slide
    31. 31. Mother of Twin Slide Mother of twins - mother in law told her she didn’t have enough for two, UNICEF 1992, Mushtaq Khan
    32. 32. Artificial jewelry Animal Milk Real Gold jewelry Breast milk Slide
    33. 33. How do we are compare Cow with calf Mother Breastfeeding Slide
    34. 34. Why Mothers do not succeed? Slide Evidence class I-III NO? No Correct information Lack of Early Assistance Embarrassed Hospital practice Work or school Fear Tied down ‘ modern’ way Marketing of formula No role Models No confidence No support
    35. 35. Manufacturing Malnutrition <ul><li>Are they parallel methods ? </li></ul>Promoting best food for baby And where is miracle <ul><li>Benefits to – </li></ul><ul><ul><li>Manufactures </li></ul></ul><ul><ul><li>Scientists </li></ul></ul><ul><ul><li>Shareholders </li></ul></ul><ul><ul><li>System </li></ul></ul><ul><ul><li>Health workers </li></ul></ul><ul><li>At which cost ? </li></ul>Sales Who its production <ul><li>Who is benefited </li></ul><ul><li>At which cost ? </li></ul>Slide
    36. 36. Marketing Confuses Mothers <ul><li>Community Practices </li></ul><ul><li>Health system </li></ul><ul><li>Commercial influences </li></ul><ul><li>Work & employment </li></ul><ul><li>Nutritional & health care </li></ul><ul><li>Attitude </li></ul><ul><li>Urbanization </li></ul><ul><li>HIV & disaster </li></ul>Confused mother Baby’s Misery Slide
    37. 37. Which photograph will increase TRP ? ( Even Media is afraid of Promoting Breastfeeding ) Which photograph will create controversy ? Malnourished baby & mother A beautiful women breastfeeding Slide
    38. 38. Milk Donations (What NGOs do for 0-6m nutrition?) Slide
    39. 39. Role of International Health Agencies Pressure groups IBFAN International Assembly of Infant food manufactories <ul><li>Mediator - Budget from 25% -US </li></ul><ul><li>70% from Industrialized countries </li></ul><ul><li>How far taking strong stands on sensitive issues ?? </li></ul>Slide
    40. 40. What is Advice <ul><li>Feed him on the left! </li></ul><ul><li>Feed him on the right! </li></ul><ul><li>Feed him in the morning, </li></ul><ul><li>Noon, and night! </li></ul><ul><li>Yeah! Breastfeeding! </li></ul>Slide
    41. 41. What is promotion? Slide
    42. 42. Slide
    43. 43. What is support? <ul><li>How can we help? </li></ul><ul><li>What will work for you? </li></ul><ul><li>We have answers that will help you </li></ul><ul><li>we can help by observing a feeding your baby </li></ul>Slide
    44. 44. Two Most Common Complaints <ul><li>“ I don’t have enough milk” </li></ul><ul><li>Find out why she thinks this </li></ul><ul><li>Find out if the baby is gaining </li></ul><ul><li>Inquire about baby’s urine output </li></ul><ul><li>Inquire about what medications, </li></ul><ul><li>including birth control meds that she is </li></ul><ul><li>taking or has been given </li></ul>Slide
    45. 45. When a mother thinks… <ul><li>She does not have enough milk </li></ul><ul><li>Her first response is to supplement </li></ul><ul><li>with formula </li></ul><ul><li>This causes her supply to diminish </li></ul><ul><li>Exactly the opposite of what </li></ul><ul><li>We want to happen! </li></ul>Slide
    46. 46. Two Most Common Complaints <ul><li>“ I have sore nipples” </li></ul><ul><li>Most common cause of sore nipple is </li></ul><ul><li>poor positioning and latch </li></ul><ul><li>Mothers want hands-on help with </li></ul><ul><li>breastfeeding </li></ul><ul><li>Mothers are NOT embarrassed by hands- </li></ul><ul><li>on help </li></ul>Slide
    47. 47. Slide
    48. 48. Slide
    49. 49. Two Most Common Complaints <ul><li>“ I have sore nipples” </li></ul><ul><li>If your help with positioning and latch </li></ul><ul><li>doesn’t improve the pain within 24-48 </li></ul><ul><li>hours, refer on!!! </li></ul><ul><li>Remember that the second most common reason for stopping breastfeeding is sore </li></ul><ul><li>nipples…so act quickly!!! </li></ul>Slide
    50. 50. Effective Communication Explore Feelings Information, Options, Suggestions Respect Identify & Praise right things Accept what she ‘ thinks’ or feels Listen carefully Ask open ended questions Provide Practical Help Slide Evidence class I-II
    51. 51. New 2006 WHO Guidance ( HIV and 0-6 Months) <ul><li>Exclusive breastfeeding does carry lower risk of HIV transmission than mixed feeding </li></ul><ul><li>HIV-infected infants should continue to be breastfed </li></ul><ul><li>Repeated assessments of feeding choice with mother </li></ul><ul><li>Breastfeeding beyond 6 months may be best for some HIV-exposed infants </li></ul><ul><li>Counselling should focus on 2 main options (replacement feeding and exclusive breastfeeding for 6 months), with other local options discussed only if mother interested </li></ul><ul><li>Home-modified animal milk no longer recommended for all of first 6 months – only to be used as short-term measure </li></ul>Slide
    52. 52. <ul><li>The state shall regard the raising the level of nutrition and the standard of living of it’s people and the improvement of public health as amongst it’s primary duties _ _. </li></ul><ul><li>Constitution of India, Article 47 </li></ul>Slide
    53. 53. <ul><li>If you believe in the importance of breastfeeding to mother and baby and you have imagination and determination and develop the necessary skills ; </li></ul><ul><li>even in most difficult situations you may find a way _ _. </li></ul><ul><li>- Thanks - </li></ul>Slide