Evidence for infant and young child survival

Dr Arun Gupta MD FIAP

Overview

State of Child Nutrition and Survival India and AP.

Evidence for infant and young child survival State of breastfeeding/IYCF practices in India

and AP What can be done to enhance breastfeeding

rates? How can we do it?

First year is critical!First year is critical!

Malnutrition strikes the most in infancy beginning in 3-4Malnutrition strikes the most in infancy beginning in 3-4 thth month , 29-30 % at 6 months, goes up and peaks about month , 29-30 % at 6 months, goes up and peaks about 46% by 18 months, flat curve after that (NFHS 3).46% by 18 months, flat curve after that (NFHS 3).

Years of life

Brain development

Underweight (-2sd) NFHS-3

Over 60 million

10 lakh children

die during

first month,

14 lakhs by

1 year, and 20 lakhs

by 5 yrs. 2/3rd are related to poor feeding.

The AP Report Card on Infant health

India A.P. Source

Initiation of Breastfeeding within 1 hour 40.5% 47.8% DLHS-3

Exclusive Breastfeeding (0-6 months) 46.8% 43.9% DLHS-3

Complementary Feeding (6-9 months) 57.1% 55% DLHS-3

ORS Given to Children with Diarrhoea 34.2% 43.3% DLHS-3

Children 12-23 months fully immunized (BCG, measles and 3 doses each of polio/DPT)

54.% 67.1% DLHS-3

Infant Mortality Rate (IMR) per 1000 live Births

53 52 SRS Bulletin 2009

Children Under 3 Years Who are Underweight

32.5% 42.5% NFHS-3

Children (age 9 months and above) received at least one dose of vitamin A

supplement)

54.5% 78.8% DLHS-3

Estimated Number of Babies Who Die Every Year

India 14 Lakhs Under 1 yr. 20 Lakhs Under five yrs.

Andhra Pradesh. 1 lakh under one year

Numbers….in AP Population : 8.2 Crore Number of children born : 18.85 Lakhs

Number of underweight under 3: 22.7 Lakhs

IMR

49

50

51

52

53

54

55

56

57

58

NFHS-3 (2005-06) SRS 2009

India A.P.

Diarrhoea

Neonatal disordersUnknown

Pneumonia

MeaslesMalaria

Other AIDSNeonatal disorders

Diarrhoea

Pneumonia

Source: Robert et al. LANCET 2003;361:2226-34

Three Major Killers

Breastfeeding is the No. 1 preventive intervention compared to any other intervention Lancet Series on child survival, and now on newborn survival : 2003 and 2004

MOSTLY PREVENTABLE

U-5 child deaths (%) saved by universlising key interventions in India

1

2

3

4

6

15

4

6

15

0 2 4 6 8 10 12 14 16

Measles vaccine

Vitamin A

Water, sanitation, hygiene

Clean delivery

Complementary Feeding

Breastfeeding

Newborn resuscitation

Antibiotics for pneumonia

Oral rehydration therapy

Percentages

Lancet Child Survival Series,2003

Deaths attributed to sub-optimal breastfeeding among children

53

18

55

20

0

10

20

30

40

50

60

Lower RespiratoryTrach (LRT)

Diarrhoeal Diseases(DD)

0-6 months6-12 months

Public Health Nutr. 2006 Sep; 9(6): 673-85

4.62

2.49

3.04

2.482.85

0

1

2

3

4

5

Diarrhoeamortality

Pneumoniamortality

Diarrhoeaincidence

Pneumoniaincidence

All causemortality

EBF

Relative risk associated with child feeding practices compared with Partial breastfeeding (LSMCU 2008)

Infection specific : Neonatal Mortality Risk by early infant feeding practices

1 1.16

2.55

3.57

0

0.5

1

1.5

2

2.5

3

3.5

4

Within onehour

One hour toone day

Day 2 Day 3

Timing of initiation of breastfeeding after birth

Infection specific mortality odd

ratio

Source: Edmond KM et al. Am J Clin Nutr 2007. 86:1126-31

Long term Impact of BREASTFEEDING

Subjects who were breastfed experienced lower mean blood pressure and total cholesterol, as well as higher performance

in intelligence tests. Prevalence of

overweight/obesity and type-2 diabetes was lower among

breastfed subjects.

WHO, 2007

Optimal Infant and Young Child Feeding

Starting breastfeeding within one hour of birth

Exclusive breastfeeding for the first six months

Introducing appropriate and adequate complementary feeding after 6 months along with Continued breastfeeding for two years or beyond

WHO: 2/3rd of all under five deaths are related to POOR FEEDING.

Feeding Practices NFHS 3 (First Year)

6.62 7.45

14.23

20.39 19.55

12.77

Initiation ofBreastfeeding within 1

hours of birth

Exclusivebreastfeeding (0-6

months)

ComplementaryFeeding (6-9 months)

Millions

Yes No

Trends in 3 indicators

15.8

41.235

24.5

46.4

56.7

40.246.4

23.9

0

20

40

60

Initiation ofBreastfeeding within 1

hour of birth

Exclusive breastfeeding(0-6 months)

Complementary Feeding(6-9 months)

NFHS-2 (98-99) NFHS-3 (2005-06) DLHS-3 (2007-08)

State of IYCF in AP

And Some other indicators

Feeding practices in AP and neighbors

47.843.2

55

46.2

68.264.465.3

69.1

84.5

77.5

64 63

40.546.8

57.1

0

10

20

30

40

50

60

70

80

90

Children under 3 years breastfedwithin one hour of birth

Children age 0-5 monthsexclusively breastfed

Children age 6-9 monthsreceiving solid/semi-solid food

and breast milk

Andhra PradeshKarnataka Kerala Tamil Nadu India

Initiation of breastfeeding within one hour of birth - District wise in AP( DLHS 3)

22.628.929.330.2

33.4

39.940.641.641.842.346.9

50.351.151.451.652.153.354.655.656.961.662.7 65

0

20

40

60

80

100

NizamabadNalgonda

KarimnagarWarangalAdilabad

Rangareddy

Kadapa

Mahbubnagar

PrakasamHyderabad

MedakKrishna

West Godavari

Guntur

Visakhapatnam

Anantapur

NelloreKurnoolSrikakulam

Vizianagaram

KhammamChittoor

East Godavari

Districts

Percentages

0-29% scores as Red; 30-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.

Exclusive breastfeeding in first six months - District wise in AP( DLHS 3)

21.223.123.325.828.6 3033 35.136.236.537.638.440.240.541.141.542 42.4 43 43.2

47.450.355.6

0

20

40

60

80

100

NizamabadSrikakulamKarimnagarAdilabad

Mahbubnagar

Medak

Hyderabad

Visakhapatnam

GunturWarangal

Krishna

VizianagaramRangareddy

NelloreKadapa

West Godavari

AnantapurPrakasamNalgondaChittoorKurnool

Khammam

East Godavari

Districts

Percentages

0-11% scores as Red; 12-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.

NFHS 3 : AP

Some other indicators

How many women know aboutfamily planning?

High-risk births have higher mortality rates

Full Immunization Coverage by StatePercentage of children 12-23 months

Trends in Vaccination CoveragePercentage of children 12-23 months receiving vaccinations

How many children receive anganwadi centre services?Percentage of age-eligible children in areas covered by an anganwadi centre receiving services

What Can We Do to Change ?

PM’s Council on India’s Nutrition

Challenges decided on 24 Nov 2010

“..The ICDS requires strengthening and restructuring. “..with special focus on pregnant and lactating mothers and children under three.”

A nationwide campaign to educate people “…. against malnutrition so as to address issues of status of women, the care of pregnant mothers and children under two, breastfeeding, and the importance of balanced nutrition, health, hygiene and sanitation….”

Some basics…. Universalisation of reach to under two: Food, including for infants,

breastfeeding , services and Care. For enhancing exclusive breastfeeding for the first six months mothers

and babies MUST stay together, rest, food, stay at home..time for caring their baby.

For this we must have maternity benefits, women have to go to work ( IGMSY Scheme is one such action Two districts from AP West Gadavrai, and Nalgonda are included )

Skilled support in health systems or at home “Not enough milk” is a universal feeling among women which can be

improved if we could build their confidence…this can be solved by “counselling”

Strict enforcement of the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992, and Amendment Act 2003.) Recent letter from MOH and WCD is an example to follow up. No sponsorships of doctors by baby food companies or their related front organisations.

Enhancing breastfeeding rates ?

Taking action in at least 10 areas Policy coordination, making work IMS Act,

accurate information, health care system support, outreach to all families, setting right medical curriculum, maternity entitlements, support to women during HIV and emergency situations, monitoring and evaluation….the 33 country report shows gaps in all of them.

QuickTime™ and a decompressor

are needed to see this picture.

EPW Sept .2007

Evidence on What Works?

Lancet 2008 Analysis of global evidence For EX.BREASTFEEDING : One to one or

group counselling works for enhancing exclusive breastfeeding rates

For COMPLEMENTARY FEEDING : Education and counselling on complementary feeding in food secure homes, PLUS food supplements in food insecure homes

The Critical hormone link to breastfeedingThe Critical hormone link to breastfeeding

For milk ejection

Cochrane review on Support for breastfeeding mothers

Britton C et al. Cochrane Database of Systematic Reviews 2006, Issue 4.

34 trials (29,385 mother-infant pairs) from 14 countries

Additional lay support was effective in prolonging exclusive breastfeeding

WHO UNICEF training was effective in prolonging Exclusive breastfeeding

The impact of community interventions: Improving infant feeding in rural Haryana, India

The impact of community interventions: Improving infant feeding in rural Haryana, India through multiple contacts is feasible and improves uptake of other child health interventions.

Health policy and Planning 2005; 20(5):328-336.

What BPNI has done on this 19 years of experience in supporting

governments with planning, advocacy, monitoring the IMS Act, state capacity building etc.

Developed ‘3 in 1’ Infant and Young Child feeding Counselling A training programme, (Integrated breastfeeding , complementary feeding and infant feeding & HIV counselling) based on WHO UNICEF’s 3 courses.

Tried in Lalitpur in UP as district level intervention

Working with Haryana, Uttrakhand, AP, Punjab, and Bihar

Infant and young child feeding practices before and after intervention in Lalitpur District (600 villages)

39.2

6.85 4.6

57.9

24.935.8

0

20

40

60

80

100

Initiation ofbreastfeeding

within 1 hour ofbirth

Exclusivebreastfeeding for 6

months

Complementaryfoods along with

continuedbreastfeeding (6-9

months)

Percentages

Pre intervention Post intervention

Recommendations Work on recommendations of the PM’s Council on India’s

Nutrition Challenges Home visiting for under 2s as a policy : Ensure universal coverage

of key interventions including early initiation of breastfeeding , exclusive breastfeeding for the first six months, timely and appropriate complementary feeding after six months along with continued breastfeeding for two years.

Put up additional women workers as Nutrition counsellors at village level and mentors at block level

Link with growth monitoring of each child. Ensure universal coverage of ORS and immunization. Ensure universal coverage of maternity benefits. Training of all workers must include skills on Breastfeeding IYCF, at

least 3 day training for IYCF counsellors and 7 day for IYCF consultants.

IMS Act be effectively implemented. Nutrition programmes should be free from conflicts of interests.