Evidence for infant and young child survival Dr Arun Gupta MD FIAP
Jan 19, 2016
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.