11
Completing the Nutrition and Completing the Nutrition and Health Package Health Package
Dr Arun Gupta MD FIAPDr Arun Gupta MD FIAP
State Health Consultation, Bihar.State Health Consultation, Bihar.
5 March 20115 March 2011
22
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 % 6 months. Goes up and peaks by 18 month , 29-30 % 6 months. Goes up and peaks by 18 months, flat curve after that (NFHS 3)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.
33
Diarrhoea
Neonatal disordersUnknown
Pneumonia
MeaslesMalaria
Other AIDS Neonatal 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
44
Bihar IndicatorsBihar Indicators
IMR per 1000 live births (SRS Bulletin 2011)IMR per 1000 live births (SRS Bulletin 2011) 5252
Children Under 5 years who are underweightChildren Under 5 years who are underweight 55.9%55.9%
Girl's marrying before completing 18 yearsGirl's marrying before completing 18 years 45.9%45.9%
Institutional deliveryInstitutional delivery 27.7%27.7%
Mothers who received post-natal care within two weeks of Mothers who received post-natal care within two weeks of deliverydelivery
26.2%26.2%
Children 12-23 months fully immunizedChildren 12-23 months fully immunized 41.4%41.4%
Children (age 9 months and above) received at least one dose Children (age 9 months and above) received at least one dose of vitamin A supplement)of vitamin A supplement)
49.9%49.9%
Children with diarrhoea in the last 2 weeks who received ORSChildren with diarrhoea in the last 2 weeks who received ORS 22%22%
Mothers who received post-natal care within two weeks of Mothers who received post-natal care within two weeks of deliverydelivery
26.2%26.2%
55
Bihar Indicators in NumbersBihar Indicators in Numbers
Population Population (Source- Census of India 2001)(Source- Census of India 2001) 82,998,50982,998,509
Birth Rate Birth Rate (Source- SRS Bulletin January 2011)(Source- SRS Bulletin January 2011) 28.5%28.5%
Approx. No. of Children Born per Year Approx. No. of Children Born per Year 2,365,458 2,365,458
Approx. No. of Children who Die Before They are Approx. No. of Children who Die Before They are 1 1
123,004 123,004
Approx. No of Survivors Each Year Approx. No of Survivors Each Year 2,242,4542,242,454
Approx. No of Survivors Under the Age 3 Approx. No of Survivors Under the Age 3 6,727,3616,727,361
Approx. No. of Underweight Children Under the Approx. No. of Underweight Children Under the Age 3 Age 3
3,760,5953,760,595
66
Risk of neonatal mortality according to time of initiation
of breastfeeding
0.71.2
2.32.6
4.2
00.5
11.5
22.5
33.5
44.5
With in 1hour
From 1 hourto end of day
1
Day 2 Day 3 After day 3
Pediatrics 2006;117:380-386
Six times more risk of death
Additional benefits
77
Percentage of Neonatal Deaths (2-28 Percentage of Neonatal Deaths (2-28 days) Saved with Early Initiationdays) Saved with Early Initiation
Risk of neonatal death is 4 fold, if milk based fluids or solids are given to breastfed neonates
Imitation after day 1 is associated with 2.4 fold increase in risk of death
22.3
16.3
0
5
10
15
20
25
Within 1 hour 1-24 hour
Initiation of breastfeeding
PEDIATRICS 2006; 117:380-386
88
1st hour initiation cuts 22% 1st hour initiation cuts 22% of all newborn deathsof all newborn deaths
100%40%
10 Lac Neonatal Deaths
2.5 lac
If we enhance initiation of BF within one hour
2.5 lac babies will be saved
INITIATION OF BREASTFEEDING
NEONATAL DEATHS SAVED
Pediatrics 2006;117:380-386
99
U-5 child deaths (%) saved with U-5 child deaths (%) saved with key interventions in Indiakey 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
1010
Deaths attributed to sub-optimal Deaths attributed to sub-optimal breastfeeding among childrenbreastfeeding among children
53
18
55
20
0
10
20
30
40
50
60
Lower RespiratoryTrach (LRT)
Diarrhoeal Diseases(DD)
0-6 months
6-12 months
Public Health Nutr. 2006 Sep; 9(6): 673-85
1111
Long term Impact of Long term Impact of BREASTFEEDINGBREASTFEEDING
Subjects who were breastfed Subjects who were breastfed experienced lower mean blood experienced lower mean blood
pressure and total cholesterol, as pressure and total cholesterol, as well as higher performance in well as higher performance in
intelligence tests. Prevalence of intelligence tests. Prevalence of overweight/obesity and type-2 overweight/obesity and type-2
diabetes was lower among diabetes was lower among breastfed subjects.breastfed subjects.
WHO, 2007
1212
Initiation of breastfeeding within one Initiation of breastfeeding within one hour of birth in Biharhour of birth in Bihar
Pu
rba
Ch
am
pa
ran
, 7.2
Ma
dh
ub
an
i, 7
.9S
he
oh
ar,
8.3
Be
gu
sara
i, 9
.4K
ha
ga
ria
, 9.8
Pa
sch
im C
ha
mp
ara
n, 9
.8N
aw
ad
a, 9
.9G
op
alg
un
j, 1
0.5
Sh
eik
hp
ura
, 10
.5S
am
ast
ipu
r, 1
0.9
Ma
dh
ep
ura
, 11
.1S
itam
arh
i, 1
2.5
Kis
ha
ng
un
j, 1
2.8
Siw
an
, 13
.3S
up
au
l, 1
3.3
Ka
tiha
r, 1
3.4
La
khis
ara
i, 1
3.7
Pu
rnia
, 13
.8A
ura
ng
ab
ad
, 14
.4R
oh
tas,
14
.4Ja
mu
i, 1
4.8
Ba
nka
, 15
.1D
arb
ha
ng
a, 1
5.3
Sa
ran
, 15
.4M
uza
ffarp
ur,
15
.5S
ah
ars
a, 1
5.8
Ara
ria
, 18
.2Je
ha
na
ba
d, 1
8.6
Mu
ng
er,
19
.3B
ho
jpu
r, 2
0.1
Ga
ya, 2
0.6
Pa
tna
, 21
.3B
ha
ga
lpu
r, 2
2.6
Bu
xar,
23
.4N
ala
nd
a, 3
0.2
Ka
imu
r, 3
0.9
Va
ish
ali,
33
.8B
iha
r, 1
6.2
0
20
40
60
80
100
Districts
Pe
rce
nta
ge
s
0-29% scores as Red; 30-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.
1313
Exclusive breastfeeding in BiharExclusive breastfeeding in BiharS
itam
arhi
, 0.3
Gop
algu
nj, 1
.3A
raria
, 2.7
Siw
an, 2
.8D
arbh
anga
, 3.5
Beg
usar
ai, 4
.2M
adhu
bani
, 4.9
Ban
ka, 5
.1M
uzaf
farp
ur, 5
.2P
urba
Cha
mpa
ran,
5.3
Sam
astip
ur, 5
.6K
haga
ria, 6
.2P
asch
im C
ham
para
n, 6
.9G
aya,
7.3
Sup
aul,
7.7
Kis
hang
unj,
8.7
Jeha
naba
d, 1
0.9
Pur
nia,
11.
5S
heik
hpur
a, 1
2.5
Naw
ada,
12.
9K
aim
ur, 1
4M
unge
r, 1
4.2
Sar
an, 1
4.6
Kat
ihar
, 14.
8P
atna
, 15.
5B
uxar
, 16.
3R
ohta
s, 1
7.6
Lakh
isar
ai, 1
9.3
Nal
anda
, 20.
7S
heoh
ar, 2
4.4
Jam
ui, 2
5A
uran
gaba
d, 2
5.1
Mad
hepu
ra, 2
6.7
Sah
arsa
, 31
Bho
jpur
, 35.
3B
haga
lpur
, 36.
1V
aish
ali,
36.4
Bih
ar, 3
8.4
0
20
40
60
80
100
Districts
Pe
rce
nta
ge
s
0-11% scores as Red; 12-49% as Yellow; 50-89% scores as Blue; 90-00% scores as Green.
1414
Gap in Feeding Practices(DLHS 3)Gap in Feeding Practices(DLHS 3)
16.238.4
61.4
0102030405060708090
100
Children under 3years breastfed
within one hour ofbirth
Exclusivebreastfeeding
Children age 6-9months receiving
solid/semi-solid foodand breastmilk
1515
Treatment of childhood diseases Treatment of childhood diseases (DLHS-3)(DLHS-3)
22
73.7 78.8
0
20
40
60
80
100
Children withdiarrhoea in the last
2 weeks whoreceived ORS1
Children withdiarrhoea in the last2 weeks who sought
advice/treatment
Children with acuterespiratory infection
or fever in last 2weeks who soughtadvice/treatment
1616
How to complete the health How to complete the health and Nutrition packageand Nutrition package
Maternal care and nutritionMaternal care and nutritionSafe delivery Safe delivery Health check up for all ailments, newborn Health check up for all ailments, newborn infections, diarrhea, ARI, feversinfections, diarrhea, ARI, feversImmunization Immunization Growth monitoring Growth monitoring Early breastfeeding within one hourEarly breastfeeding within one hourExclusive breastfeeding for the first six months Exclusive breastfeeding for the first six months Timely and appropriate complementary feeding Timely and appropriate complementary feeding after six months along with continued after six months along with continued breastfeeding breastfeeding
1717
Core IYCF IndicesCore IYCF Indices
Early initiation of breastfeeding within one hourEarly initiation of breastfeeding within one hour
Exclusive breastfeeding for the first 6 monthsExclusive breastfeeding for the first 6 months
Continued breastfeeding at 1 year Continued breastfeeding at 1 year
Introduction of solid, semi-solid or soft foods at six Introduction of solid, semi-solid or soft foods at six monthsmonths
Minimum dietary diversityMinimum dietary diversity
Minimum meal frequencyMinimum meal frequency
Minimum acceptable diet Minimum acceptable diet
Consumption of iron-rich or iron-fortified foodsConsumption of iron-rich or iron-fortified foods
WHO, June 2010
1818
Enhancing optimal breastfeedingEnhancing optimal breastfeeding
Programmatic focus on early and exclusive Programmatic focus on early and exclusive breastfeedingbreastfeedingBuild skilled capacity among the health Build skilled capacity among the health workers both at block and village levelworkers both at block and village levelDo not allow Interference of formula industry Do not allow Interference of formula industry in planning and programmein planning and programmeEnsure maternity benefits for all womenEnsure maternity benefits for all women
1919
What is special about training What is special about training on IYCFon IYCF
2020
Confidence building measures vs. Confidence building measures vs. Information or promotionInformation or promotion
For milk ejection3/4
2121
Protecting from baby food Protecting from baby food industryindustry
2222
3 main strategies3 main strategies
Successful Breastfeeding
PROMOTION• Campaigns
• Social mobilization
PROTECTION• Code
implementation
SUPPORT• Skilled support
• Work site support• Maternity benefits
2323
4 support strategies4 support strategies
Successful Breastfeeding
EDUCATION & TRAINING
• Pre/In service• School/college
COORDINATION• Budget• Policy
RESEARCH• Programme and policy evaluation• Implementation
INFORMATION• Data collection
• Monitoring
2424
Count each child who falters Count each child who falters at the earliestat the earliest
2525
Growth chartGrowth chart
2626
Universal Growth MonitoringUniversal Growth Monitoring
Health check ups, Nutrition counselling on the way
2727
Exclusive Breastfeeding Exclusive Breastfeeding PhasePhase
2828
Complementary Feeding Complementary Feeding PhasePhase
Faltering
DietaryRecall
Growth Monitoring
Recounseling
H/O illness
2929
Compliance with MGRS feeding Compliance with MGRS feeding criteria by site and overallcriteria by site and overall
3030
WHO Growth standardsWHO Growth standards
How children should growHow children should growLactation Counseling by well trained counsellors Lactation Counseling by well trained counsellors ( 5 days training )( 5 days training )Helping/ assistance with initiation soon after birthHelping/ assistance with initiation soon after birthPreventing and resolving lactation problems.Preventing and resolving lactation problems.The first visit by a lactation counsellor within 24 h The first visit by a lactation counsellor within 24 h of deliveryof deliverySubsequent visits occurred at 7, 14 and 30 d, and Subsequent visits occurred at 7, 14 and 30 d, and monthly thereafter until the sixth month.monthly thereafter until the sixth month.
3131
‘‘3 in 1’ Training Programme3 in 1’ Training Programme
3232
What do you want to What do you want to achieve?achieve?
MotivationMotivationPreventing and solving the problem of ‘not enough Preventing and solving the problem of ‘not enough milk’milk’Building confidenceBuilding confidenceMaintenance of exclusive breastfeeding for the Maintenance of exclusive breastfeeding for the first six months first six months Prevention of breast problems like sore nipples, Prevention of breast problems like sore nipples, mastitis ( 13% in various studies)mastitis ( 13% in various studies)Timely and appropriate complementary feeding Timely and appropriate complementary feeding after six months along with continued after six months along with continued breastfeeding breastfeeding
3333
How we did it in Punjab How we did it in Punjab
10 districts10 districts
Middle level trainers : doctors and nursesMiddle level trainers : doctors and nurses
Received 6 day trainingReceived 6 day training
Imparted 3- day training to frontline Imparted 3- day training to frontline workersworkers
3434
Lalitpur ModelLalitpur Model
Breastfeeding counselling and support services have Breastfeeding counselling and support services have been created for over 2 years been created for over 2 years Graduate women trained as block mentors provides Graduate women trained as block mentors provides supervision and training to about 3 women in each supervision and training to about 3 women in each village creating a networkvillage creating a networkEarly breastfeeding ,Exclusive breastfeeding for the first Early breastfeeding ,Exclusive breastfeeding for the first six months and complementary feeding all have shown six months and complementary feeding all have shown improvement significantly.improvement significantly.
3535
Infant and young child feeding practices Infant and young child feeding practices before and after intervention in Lalitpur before and after intervention in Lalitpur
District (600 villages)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)
Per
cen
tag
es
Pre intervention Post intervention
3636
MEP..the minimum essential MEP..the minimum essential programme of services in NRHMprogramme of services in NRHM
Nutrition support to mothers, maternity Nutrition support to mothers, maternity benefits ,IGMSY, benefits ,IGMSY, Family counsellorsFamily counsellors IYCF by a 3 day training, at birth IYCF by a 3 day training, at birth assistance, assistance, home visitshome visits 4 in 2 weeks, 4 in 2 weeks, and then every 2 weeks for 2 months, and then every 2 weeks for 2 months, and every month till 12 monthsand every month till 12 months
Family
Cluster of 5-10
Block/PHC
District level and above, medical colleges.
Block Mentors of IYCFBlock Mentors of IYCF, act as , act as trainers, supervisors, support on trainers, supervisors, support on difficult problems in Breastfeeding like difficult problems in Breastfeeding like not enough milk, engorgement, not enough milk, engorgement, mastitis etc.mastitis etc.
SPECIALIST SPECIALIST COUNSELLOR on COUNSELLOR on IYCFIYCF IN ALL PUBLIC AND PRIVATE HOSPS
3737
Thanks !Thanks !