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Indicators and dilemma of breast feeding assessment last

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Indicators and dilemma of breast feeding assessment last

  1. 1. Indicators and Dilemma of Breastfeeding practices Assessment By Tarek A. Abd-El Rahman, MD. Lecturer of Public health- El Minia University , 01002416891
  2. 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?
  3. 3. Value of Breastfeeding
  4. 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. 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. 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. 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. 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
  9. 9. Historical Background :
  10. 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. 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. 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. 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. 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. 15. 2008 WHO release PART 1 regarding those efforts titled “Indicators for assessing infant and young child feeding practices” Part 1 Definitions
  16. 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. 17. 2010 WHO release PART where thirteen of the above indicators are presented by country.
  18. 18. 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.
  19. 19. 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
  20. 20. 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
  21. 21. 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)
  22. 22. 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
  23. 23. Purpose of Indicators
  24. 24. 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.
  25. 25. 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.
  26. 26. 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.
  27. 27. 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.
  28. 28. 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
  29. 29. 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.
  30. 30. 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 ?
  31. 31. Summary list of infants & young child feeding indicators
  32. 32. Criteria that define selected infant feeding practices
  33. 33. Dilemmas related to definition & application of some individual indicators
  34. 34. 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.
  35. 35. 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.
  36. 36. • 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
  37. 37. 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 )
  38. 38. 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
  39. 39. 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)
  40. 40. 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
  41. 41. 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 .