1. Dr. K P Kushwaha
Prof & Head,
BRD Medical College, Gorakhpur

2. Evidence classification
Evidence class Criteria for evidence
• Class I • Randomized control trial
;at least one
• Class II • Well organized control
trials without
randomization, cohort or
case control ,cross
sectional, retrospective
;more than one
• Class III • Case reports, reports of
expert comittees,
guidelines,

3. Infant feeding Recommendations
(Global strategies for Infant & Young
Child Feeding)
• Exclusive breastfeeding form birth to 6 months
• Appropriate complementary feeding after 6 months
+ Breastfeeding
• Sustaining breastfeeding for 2 years and beyond
• Related maternal, nutrition & care
• Building community support and health system
support protecting infant feeding practices from
commercial influences
Slide 3

4. Infant feeding Recommendations
(Global strategies for Infant & Young
Child Feeding)
• Preterm, ELBW, VLBW and above 1600gm. All need
breastmilk.
• Feeding method and approaches are varied.
Slide 4

5. HIV :2000 and 2006 WHO Recommendations
•When replacement feeding • Exclusive breastfeeding is
is acceptable, feasible, recommended for HIV-infected
affordable, sustainable and women for the first 6 months of life
safe, avoidance of all unless replacement feeding is
breastfeeding by HIV- acceptable, feasible, affordable,
infected mothers is sustainable and safe for them and
recommended. their infants before that time.
• When replacement feeding is
• Otherwise, exclusive
acceptable, feasible, affordable,
breastfeeding is
sustainable and safe, avoidance of all
recommended during the first
breastfeeding by HIV-infected
months of life.
women is recommended
Slide 5

6. IYCF Practices-India
• Initiation with in 1 Hr • 23.4
• Exclusive Breastfeeding • 46.3
• Timely (appropriate ?) • 55.8
complement
• Sustained breastfeeding 2 • 38.4
years and beyond
(Squeezing and discarding of colostrum and
prelacteal feeds are quite common)
Source: NHFS-3
Slide 6

7. Trends in Nutritional Status
Percent of children age under 3 years
NFHS-3 NFHS-2
51
45 43
40
23
20
Stunted Wasted Underweight
(Low-height-for-age) (Low-weight-for-height) (Low-weight-for- age)
Source: NHFS-2 & 3
Slide 7

8. Anaemia among Children
Percent of children 6-35 months with anaemia
79 81
72 74
Total Urban Rural NFHS-2
Slide 8

9. How Many Children Receive Services
from an AWC?
ICDS (??? 0 – 6 yrs )
80 Percent of age-eligible children in areas with an AWC
70
60
50
40 33
30 26
23
20 18
20 16
10
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How many 0-6 ms are being looked after?
Source: NHFS-3 Slide 9

10. Benefits to Baby (evidence class I –III)
• Optimum growth
• Brain growth
• Reduce risk for:
– Undernutrition
– Upper and lower respiratory infections
– Otitis media (ear infections)
– Urinary tracts
– Sytemic Infections
– Gastroenteritis
– Allergies
– Overweight/obesity
– SIDS
Slide 10

11. Why Breast milk for preterm
• To Protect
- Infections
- NEC
• To Provide
- PUFA, growth factors, hormone, tropic factors
- Better visual and cognitive development
• To Involve mother in care, including KMC
• To Provide nutrition's with high bio availability
Evidence class I
Slide 11

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)
2.8
2.6
2.4
LDL to HDL ratio
2.2
2
1.8
1.6
Evidence class I
1.4
1.2
1
Lowest 3rd (13%) Middle Third (65%) Highest Third (100%)
Human Milk Intake
Slide 12

13. Breast milk composition
differences (dynamic)
• Gestational age at birth
(preterm and full term)
• Stage of lactation
(colustrum and mature milk)
• During a feed
(foremilk and hindmilk)
Evidence class I
Slide 13

14. Slide 14

15. Slide 15

16. Colostrum ( evidence class I-
III )
Property Importance
• Antibody ich
- r • protects against infection and
allergy
• Many white cells • protects against infection
• Purgative • clears meconium; helps
prevent jaundice
• Growth factors • helps intestine mature;
prevents allergy, intolerance
• Vitamin
- A
rich • reduces severity of some
infection (such as measles and
diarrhoea); prevents vitamin
A related eye diseases
-
Slide 16

17. Slide 17

18. More Benefits to Baby
(When they grow)
• Reduced risk for:
- Dental disorders
– Diabetes
– Crohn’s disease
– Childhood Leukemia
– Cardiovascular
disease
– Celiac disease
– Rheumatoid arthritis
Evidence class II -III
Slide 18

19. Benefices for Mom
• Rapid recovery after having a baby
• Decreases risk of anemia
• Weight reduction
• Reduces risk of breast cancer
• Reduces risk of ovarian cancer
• May reduce risk of endometrial cancer
• Reduces risk for osteoporosis
• Delays next pregnancy
Evidence class II -III
Slide 19

20. Community
Benefits
Breast milk is a
Fewer healthcare
New parents miss Natural and
Visits & lower
Less work Renewable
Treatment costs
resource
Evidence class III
Slide 20

21. Breastfeeding prevents under
nutrition and obesity
Under nutrition 40-50%
Obesity 50%
Evidence class II-III

22. Breastfeeding decreases the prevalence
of obesity in childhood at age five and six years,
Germany
5 4.5
4.5
4 3.8
Prevalence (%)
3.5
0 months
3
2.3 2 months
2.5
1.7 3-5 months
2
1.5 6-12 months
1
0.5
0
months breastfeeding
Adapted from: von Kries R, Koletzko B, Sauerwald T et al. Breast feeding and
obesity: cross sectional study. BMJ, 1999, 319:147-150.
Slide 22

23. Higher Intelligence quotient ( Evidence class I-II)
BF 12.9 points
BF 2 points higher than FF
higher than FF Study in 9.5
year-olds
Study in 3-7
1996
year-olds
1982
BF 8.3 points
higher than FF
Study in 7.5-8
BF 2.1 points year-olds
higher than FF 1992
Study in 6 months
to 2 year- olds References:
1988 BM 7.5 points •Fergusson DM et al. Soc
higher than no BM SciMed 1982
•Morrow-Tlucak M et al.
Study in 7.5-8 SocSciMed 1988
BF = breastfed year-olds •Lucas A et al. Lancet 1992
FF = formula fed •Riva Eet al. Acta Paediatr 1996
BM = breast milk 1992
Slide 23

24. Potential Child Mortality Reduction
from Preventive Interventions
Deaths prevented
Number as proportion of
Preventive Intervention (thousands) 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%
Jones et al. How many deaths can we prevent this year? Lancet 2003 Slide 24

25. The value of breast milk
to the national economy in India
• 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.
• If the breast milk produced were replaced by tinned milk,
it would cost 118 billion Rupees.
• If imported, the breast- m substitutes would cost 4.7
ilk
million USD.
• If breastfeeding practices were optimal, breast milk
production would be twice the current amount, doubling
the savings by fully utilizing this “national resource”.
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 25

26. Comparative health care costs of treating breastfed
and formula-fed babies in the first year of life in a
health maintenance organization (HMO)
When comparing health statistics for 1000 never breastfed
infants with 1000 infants exclusively breastfed for at least 3
months, the never breastfed infants had:
• 60 more lower respiratory tract illnesses
• 580 more episodes of otitis media, and
•1053 more episodes of gastrointestinal illnesses
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 26

27. In addition, the 1000 never-breastfed infants
had:
• 2033 excess office visits
• 212 excess hospitalizations
• 609 excess prescriptions
These additional health care services
cost the managed care system
between $331 and $475 per never- b reastfed infant
during the first year of life.
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

28. Slide 28

29. What is the infant mortality risk
from not breastfeeding?
12
Pooled Odds Ratios Ghana
10
Lowest tercile of
8 mat. education
6
4
2
0
0-1 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo 12-24 mo
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.
Slide 29

30. The baby Killer
(Andy Chetley/war on want, 1974)
• Sale of formula in India Rs
• Sale of Bottles in India Rs
Slide 30

31. Mother of Twin
Mother of twins - mother
in law told her she
didn’t have enough
for two, UNICEF 1992,
Mushtaq Khan
Slide 31

32. Artificial jewelry Real Gold jewelry
Animal Milk Breast milk Slide 32

33. How do we are compare
Cow with calf Mother Breastfeeding
Slide 33

34. Why Mothers do not succeed?
Marketing
of No
Lack of formula role
Early Models
Assistance No
confidence
Hospital
practice
No
support
NO?
‘modern’
way No
Correct
information
Fear
Tied down
Evidence class I-III Work or Embarrassed
school
Slide 34

35. Manufacturing Malnutrition
Are they parallel methods ?
Promoting best food for baby And where is miracle
Sales Who its
production
• Benefits to –
– Manufactures • Who is benefited
– Scientists • At which cost ?
– Shareholders
– System
– Health workers
• At which cost ? Slide 35

36. Marketing Confuses Mothers
Confused mother Baby’s Misery
• Community Practices • Nutritional & health
• Health system care
• Commercial influences • Attitude
• Work & employment • Urbanization
• HIV & disaster
Slide 36

37. Which photograph will increase TRP ?
(Even Media is afraid of Promoting Breastfeeding)
Malnourished baby & A beautiful women
mother breastfeeding
Which photograph will create controversy ?
Slide 37

38. Milk Donations
(What NGOs do for 0-6m nutrition?)
Slide 38

39. Role of International Health
Agencies
• Mediator - Budget from International
Pressure 25% -US
groups Assembly
• 70% from of Infant food
IBFAN Industrialized countries
manufactories
• How far taking strong stands on sensitive issues ??
Slide 39

40. What is Advice
Feed him on the left!
Feed him on the right!
Feed him in the morning,
Noon, and night!
Yeah! Breastfeeding!
Slide 40

41. What is promotion?
Slide 41

42. Slide 42

43. What is support?
• How can we help?
• What will work for you?
• We have answers that will help you
• we can help by observing a feeding your baby
Slide 43

44. Two Most Common Complaints
“I don’t have enough milk”
Find out why she thinks this
Find out if the baby is gaining
Inquire about baby’s urine output
Inquire about what medications,
including birth control meds that she is
taking or has been given
Slide 44

45. When a mother thinks…
She does not have enough milk
Her first response is to supplement
with formula
This causes her supply to diminish
Exactly the opposite of what
We want to happen!
Slide 45

46. Two Most Common Complaints
“I have sore nipples”
Most common cause of sore nipple is
poor positioning and latch
Mothers want hands-on help with
breastfeeding
Mothers are NOT embarrassed by hands-
on help
Slide 46

47. Slide 47

48. Slide 48

49. Two Most Common Complaints
“I have sore nipples”
If your help with positioning and latch
doesn’t improve the pain within 24-48
hours, refer on!!!
Remember that the second most common
reason for stopping breastfeeding is sore
nipples…so act quickly!!!
Slide 49

50. Listen
carefully
Ask open
ended
questions
Respect
Provide
Practical
Effective Help
Accept Communication
what she
‘thinks’ or
feels
Explore
Feelings
Identify & Information,
Evidence class I-II Praise right Options,
things
Suggestions
Slide 50

51. New 2006 WHO Guidance
(HIV and 0-6 Months)
• Exclusive breastfeeding does carry lower risk of HIV
transmission than mixed feeding
• HIV-infected infants should continue to be breastfed
• Repeated assessments of feeding choice with mother
• Breastfeeding beyond 6 months may be best for some
HIV-exposed infants
• Counselling should focus on 2 main options
(replacement feeding and exclusive breastfeeding for
6 months), with other local options discussed only if
mother interested
• Home-modified animal milk no longer
recommended for all of first 6 months – only to be
used as short-term measure
Slide 51

52. • 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 _ _.
Constitution of India, Article 47
Slide 52

53. • If you believe in the importance of
breastfeeding to mother and baby and
you have imagination and
determination and develop the
necessary skills ;
even in most difficult situations you may
find a way _ _.
Slide 53
-Thanks-