Indicators and dilemma of breast feeding assessment last
1. Indicators and Dilemma of
Breastfeeding practices
Assessment
By
Tarek A. Abd-El Rahman, MD.
Lecturer of Public health- El Minia University
Tarek1.mohamed@mu.edu.eg , 01002416891
2. Presentation Overview
• Value of Breastfeeding
• Historical background
• Why we are in need for assessment indicators
of Breastfeeding practices ?
• Purpose of those indicators
• Critical reading regarding Dilemmas of the last
updated indicators of breastfeeding
• Is there a future prospects of Indicators?
4. Value of Breastfeeding
• A major component of care is the set of
practices caregivers employ to provide breast
milk and complementary foods to children in
1
their first years of life .
• In order to reach a healthy growth &
development of a child , he must be given a
2
proper care .
1) PAHO/WHO2003 , 2) Engle et al. 1996
5. Value of Breastfeeding
• Children who are poorly nourished in
the first 2 years of life are at
increased risk of mortality and
impaired cognitive development, as
well as diminished work capacity and
1
chronic disease later in life .
1) Dewey &Begum 2011.
6. Value of Breastfeeding
• Malnutrition has been responsible
directly or indirectly, for 60% of the 10.9
million deaths annually among children
under five. Well over two-thirds of these
deaths, which are often associated with
inappropriate feeding practices, occur
during the first year of life.
7. Bad News From MDG report 2013
• Despite , The well-established benefits of
age-appropriate feeding practices for
infants and young children that should be
applied throughout the continuum of care,
including timely initiation of breastfeeding
(within one hour of birth), exclusive
breastfeeding for the first six months of a
child’s life, and continued breastfeeding for
two years or more.
The Millennium Development Goals Report 2013
8. Bad News From MDG report 2013
• Globally, less than half of newborns
were breastfed within the first hour
of birth and only 39 % of children
were breastfed exclusively for the
first six months.
The Millennium Development Goals Report 2013
10. Historical Background of breastfeeding
indicators :
• 1991 : The document “Indicators for
assessing breastfeeding practices”
provided a set of indicators that could be
used to assess infant feeding within and
across countries and evaluate the progress
of breastfeeding promotion efforts.
• After critical reading to those indicators regarding it had
only one indicator of complementary feeding – the timely
complementary feeding rate, as it provided only information
about whether complementary foods were consumed, but not
about the quantity or quality of those foods.
11. • 2002 in response to this concern, WHO began
a process to review and develop indicators of
complementary
feeding
practices.
A
conceptual
framework
for
identifying
potential indicators of complementary feeding
practices was published
• 2003 Guiding Principles for Complementary
Feeding of the Breastfed Child were being
developed, which addressed the
multidimensionality of complementary
feeding practices *
* WHO/PAHO. Guiding principles for complementary feeding of the breastfed child. Washington, DC, Pan American
Health Organization, 2003.
12. • 2004-2005 A similar effort to develop
guidance and rationale for feeding nonbreastfed children 6–23 months of age was
undertaken shortly thereafter, which resulted
in a technical document 1 and a parallel set of
Guiding Principles2
1) Dewey KG, Cohen RJ, and Rollins NC. Feeding of non-breastfed children 6–24 months of age in developing
countries. Food and Nutrition Bulletin 25, 2004, 377–402.
2) Guiding principles for feeding non-breastfed children 6–24 months of age. Geneva, World Health Organization,
2005.
13. • 2004 a series of activities aimed towards
definition and validation of indicators to
reflect dietary quality and quantity, using
existing data sets from 10 different sites in
developing countries.
• In addition to using the references listed
above as guidance, the Working Group was
also guided by the recommendations and
targets of the Global Strategy for Infant and
Young Child Feeding *
* WHO/UNICEF. Global Strategy on Infant and Young Child Feeding. Geneva, World Health Organization,
2003.
14. • 2006 A report was released by the working
group which summarized their analysis of
those indicators 1
• lastly in 2007 additional analyses to address
the remaining questions and concerns were
subsequently completed and described in a
report submitted 2
1) Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality and
energy intake of infants and young children in developing countries: Summary of findings from analysis of 10 data sets. Repor
2) Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality of
infants and young children in developing countries: Additional analysis of 10 data sets. Report submitted to: the Food and
Nutrition Technical Assistance (FANTA) Project/Academy for Educational Development (AED), July 2007
15. 2008 WHO release PART 1 regarding those efforts titled
“Indicators for assessing infant and young child feeding
practices” Part 1 Definitions
16. 2010 WHO release PART 2 in order to improve the
measurement and use of indicators to assess infant and young
child feeding practices
17. 2010 WHO release PART where thirteen of the above
indicators are presented by country.
18.
19. Why we are in need for assessment
indicators of Breastfeeding practices ?
1) We need is to fill the gap in assessment of
breastfeeding practices by analyzing the
relationship between the implementation of
the WHO/UNICEF Global Strategy for Infant
and Young Child Feeding as measured by the
World Breastfeeding Trends Initiative (W.B.T.i)
and trends in EBF and BF duration over the
past 20 y.
20. Why we are in need for assessment
indicators of Breastfeeding practices ?
2) To address the problems related to poor
feeding practices that represent major threats
to social and economic development in the
infant & young child groups”.
3) To assess progress in the implementation of
the Global Strategy, regarding assessing
national practices, policies, and programs in
support of infant and young child feeding
21. Why we are in need for assessment
indicators of Breastfeeding practices ?
4) we need to help users assess the strengths
and weaknesses of policies and programs for
protecting, promoting, and supporting
optimal feeding practices in their local setting
and to determine where improvements may
be needed to meet the aims and objectives of
the Global Strategy
22. Members of the working group on
infant and young child feeding
indicators
The working group had a :
• Permanent steering team “ 5 of them were working in
organizations settled in Washington DC, USA , only
one was in WHO , Geneva, Switzerland
• Large number of contributors in the form of 10
principle investigators involved in 10 sites analysis
(The Philippines, India, Peru, Davis, USA, Washington,
DC, USA, Montpellier, France, Cali, Colombia)
23. List of participants in the Global consensus meeting
on Indiactors of Infant and Young Child Feeding 6-8
November , 2007 , Washington, DC
They were 20 participants, Majority of them
belong to Americas region and representing
organizations or institutes their
The composition of the working group (
Steering team and 10 principle investigators )
and list of participants in consensus meeting
both are lacking considerable representation
of all parts of the world especially EMRO and
more specifically our Arab world
25. Purpose of the indicators:
Assessment
Targeting
Monitoring
and evaluation
• to make national and sub-national
comparisons and to describe trends
over time
• to identify populations at risk, target
interventions, and make policy decisions
about resource allocation
• to monitor progress in achieving goals
and to evaluate the impact of
interventions.
26. Dilemmas related to purpose of indicators
• Those indicators have many limitations regarding their
usage :
1) They are mainly designed for use in large-scale
surveys or national programs.
2) If used in Smaller local and regional programs their
limited set of measures is not intended to meet all of
the needs for program monitoring and evaluation at
this level .
3) Programs and projects should augment these with
more specific indicators that reflect their own
interventions, messages, and behavior change
objectives.
27. Dilemmas related to purpose of indicators
4) The indicator definitions should not be translated
into caregiver messages for improving feeding
practices in young children. These should be derived
from the detailed Guiding Principles
5) The indicators described in this document are meant
to be considered together, not in isolation, because
of the multi-dimensional aspects of appropriate
feeding at this age. It is therefore recommended that
in surveys, efforts be made to assess data on the full
set of indicators for any given population.
28. Dilemmas related to purpose of indicators
6) Lastly in dealing with indicators with
narrow age ranges in the numerator and
the denominator, we could not use them
in small sample sizes smaller scale
programs.
29. Methodology for measuring Indicators
• The proposed indicators should be derived
from interviews conducted at the household
level using a household survey methodology,
so we could not use MCH ( maternal and child
health care centers) as a place for obtaining
data
30. Methodology for measuring Indicators
• The previous-day recall period was selected
(widely used and found appropriate in surveys
of dietary intake in populations), but because
practices vary from day to day , so indicators
derived from the previous day recall period
should not be used to make assessments of
dietary adequacy at the level of the individual.
31. Methodology for measuring Indicators
• Relative to the 1991 guidance, one modification was
made with regard to the criteria for exclusive
breastfeeding. Since ORS is a medicine, it was agreed
to allow this under the definition of exclusive
breastfeeding. Exclusive breastfeeding now means that
the infant receives breast milk (including expressed
breast milk or breast milk from a wet nurse) and allows
the infant to receive ORS, drops, syrups (vitamins,
minerals, medicines), but nothing else.
• N.B: why we do not consider herb syrups like carawy
etc., as some sort of a medicine like ORS ?
35. Core indicators : breastfeeding initiation
1) Early initiation of breastfeeding
•
•
The denominator and numerator include living
children and deceased children who were born
within the past 24 months. So it must be applied in
a household survey only.
A note must be added that it does not matter
whether or not the mother milk had arrived at the
time of first putting the child to the breast.
36. Core indicators : Exclusive breastfeeding
2. Exclusive breastfeeding under 6 months
•
This indicator uses the previous day recall period and this
will lead to overestimation of exclusively breastfed infants,
as some infants who are given other liquids irregularly may
not have received them in the day before the survey.
37. • The following 3rd & 4th indicators named
*continued breastfeeding at 1 year
* Introduction of solid , semi-solid or soft foods
both of them has a very narrow age range of 3
months , estimates from surveys with small
sample sizes are likely to have wide confidence
intervals
38. Core indicators : Dietary diversity
• Minimum dietary diversity: Proportion of children 6–23
months of age who receive foods from 4 or more food groups
•
If diversity scores directly compared for breastfed and nonbreastfed children this may lead to miss judgments regarding
their situation , hence this indicator may show ‘better’
results for children who are not breastfed than those who
are breastfed in populations where formula and/or milk are
commonly given to non-breastfed children ( N.B. Breast milk
is not counted )
39. Remaining Core indicators : minimum meal frequency ,
Minimum acceptable diet & consumption of iron-rich or
iron-fortified foods
• All of them needs consultation of a nutrition
expert in country pattern with further
detailed description of local types of foods
that differs between countries and even
between different country provinces
• All those indicators are requiring further
disaggregation into small age groups
40. Optional indicators : Predominant breastfeeding
under 6 months
• Comment : this indicator is suitable to be applied her
in Egypt where we are having a quite low proportion
of exclusively breastfeeding infants aged les than 6
months , because the intent of this indicator is to
identify infants whose predominant source of
nourishment is breast milk , but who receive other
fluids (other than non human milk and food based
fluids)
41. Conclusions :
• All those indicators needs further revisions
and individualization for each country
according to the its health and nutritional
status
• A more practical tools for assessment of infant
and young child feeding , are needed
especially in low income and developing
countries
42. Conclusions :
• We need to constitute a panel from our
national experts in the fields of
nutrition, public health , pediatricians
and motivated stake holder in order to
create our own indicators for
assessment of breastfeeding practices .
