Exclusive breastfeeding for first six Exclusive breastfeeding for first six months :Core Issuesmonths :Core Issues

Planning workshop IYCF, Vietnam.Planning workshop IYCF, Vietnam.15-16 September,2003. Hanoi.15-16 September,2003. Hanoi.

Dr. Arun Gupta MD FIAPDr. Arun Gupta MD FIAP

Regional coordinator IBFAN Asia Pacific, India New Delhi.Regional coordinator IBFAN Asia Pacific, India New Delhi.

Greetings from India !Greetings from India !

Evolution of the new Evolution of the new recommendation on Exc. Bf.recommendation on Exc. Bf.

• Evidence based • 1993-1994 first evidence was available• Took 7 years for consensus building• No body knew the origin of earlier

recommendation of period of exclusive breastfeeding to be 4-6 months, it was an assumption

• Definition was indirectly taken from the “International Code for Marketing of Breast-Milk Substitutes” which defined marketing of breastmilk substitutes.

Global ConsensusGlobal Consensus

• 1994 : WABA• 1994 : IBFAN• 1994: UNICEF• 2000: Global Technical consultation• 2001: WHO Technical Review• 2001: World Health Assembly adopts resolution 54.2

May 2001.• 2002: Global Strategy on Infant and Young Child

Feeding adopted at World Health Assembly through resolution 55.25, May 2002 and UNICEF Executive Board in September 2002.

70 Countries have adopted the policy so far.

WHO Expert Technical WHO Expert Technical ConsultationsConsultations

• 2000 Global Technical Consultation : 28 experts recommend exclusive breastfeeding for “about six months”

• An external peer review • 2001(March) A systematic review of current

scientific evidence on the optimal duration of exclusive breastfeeding: 3000 papers , short listed, and expert group recommended “exclusive breastfeeding for 6 months, with introduction of complementary foods and continued breastfeeding thereafter”.

Core IssuesCore Issues

1. Do we ALL know about it?

2. Is it possible to achieve?

3. What will bring a change ?

4. What is the best time for interventions?

1.Do ALL know about it?1.Do ALL know about it?

• Policy makers , Health professionals, care providers at all levels, Distt/Commune, families

• Several views of professionals

• Some times personal views

It calls for action

2. Is it possible to achieve2. Is it possible to achieve

• YES

• Evidence from different parts of the world is available

It underlines need for action in Vietnam

0

20

40

60

80

100

Brazil '98 Mexico '99 Sri Lanka '99 Bangladesh '98 Bangladesh '96

Exc

lusi

ve b

reas

tfee

ding

(%

)

Control

Counselled

3 months 3 months 4 months 5 months

Breastfeeding counseling increases exclusive breastfeeding

All differences between intervention and control groups are significant at p<0.001.Source: CAH/WHO, work in progress . References available upon request.

Age:

(Haider)(Albernaz) (Morrow) (Jayathilaka) (Haider)

2 wks after diarrhoeal treatment

Effect of breastfeeding support household visits by Effect of breastfeeding support household visits by trained local motherstrained local mothers

(Bangladesh)(Bangladesh)

0

20

40

60

80

100

1 2 3 4 5

Infants age in months

Received support visits Control group

Haider R, Ashworth A, Kabir I et al. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomized, controlled trial. The Lancet 2000;356:1643-1647.

Effect of intervention on reported Effect of intervention on reported breastfeeding practices at age 3 months breastfeeding practices at age 3 months

(India)(India)

50%

31%

79%

24%

75%

48%

0%

20%

40%

60%

80%

100%

Initiation of breastfeedingwithin 3 hours

Prelacteal feeds given Exclusively breastfed at 3months

Intervention Control

Source: Nita B et al. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet, 361, April 2003

Effect of intervention on reported Effect of intervention on reported breastfeeding practicesbreastfeeding practices

• Duration of exclusive breastfeeding in days

122

41

- 20 40 60 80 100 120 140

Intervention

Control

Source: Nita B et al. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet, 361, April 2003

Timely Initiation of Breastfeeding Timely Initiation of Breastfeeding (Madagascar, Ghana, Bolivia)(Madagascar, Ghana, Bolivia)

34% 32%

56%

69%62%

69%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Madagascarn1=699,n2=199p<0.001

Ghana n1=454,n2=377p<0.001 Bolivia n1=4327,n2=2580p<0.001

2000 2001

LINKAGES study

3.What will bring a change?3.What will bring a change? Behavior change

Behaviour changeBehaviour change

• Common reasons which do not allow Exclusive breastfeeding : Not enough milk.

• Lack of support and information is universal

• To solve this problem , we need to build confidence among women

• This can come only through skilled counseling.

Behavior changeBehavior change

Aim at behaviour change To affect • the decision making of the mother or families, • her motivation to overcome problems if they do come, • countering negative pressures and • persisting with recommended behaviour, It is important that interventions are as close as

possible to desired change.• To achieve so much e.g. avoid prelacteal feeds/ or water

for example, provide complementary feeding at 6 months, we have to make serious efforts.

Behaviour changeBehaviour change

• To increasing women’s confidence and motivation to sustain a behaviour, demonstration of success is important.

• For example : Letting her try for 2 days of exclusive breastfeeding and then see if it works, she will be much more confident to maintain that rather than asking for 6 months straight.

• It is the result of skillful acts• Inputs are needed at services and family

level

4.What is the best time for 4.What is the best time for interventions? interventions?

1. Intervene as close as possible to behaviour change.

2. Most beneficial for survival.

Protection by breastfeeding is greatest Protection by breastfeeding is greatest for the young infantsfor the young infants

Risk of death if breastfed is equivalent to one.

0123456

1 2 3 4 5Age in months

Tim

es m

ore

like

ly t

o d

ie if

n

ot

bre

astf

ed

WHO collaborative Study Team. Effects of Breastfeeding on infant and child mortality due to infectious disease in less developed countries a pooled analysis. The Lancet 2000;355:451-5

Protection by breastfeeding is maximum within Protection by breastfeeding is maximum within first 2 monthsfirst 2 months

• Relative risk of death increases with partially breastfeeding and is highest if not breastfed within first 2 months.

23.3

14.2

4.2

0

5

10

15

20

25

Partially breastfed Not breastfed Not breastfed infirst 2 months

Victora CG, Smith PG, Vaughan JP, et al. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. Lancet iii: 1987; 319-322.

Remember !Remember !

To be effective HOW WELL WE DO is more important

than WHO does WHAT

Conclusions and what next ?Conclusions and what next ?

• New recommendation is scientific and accepted world over.

• We all should know this• Finally : Transfer what we know into ACTION• It is possible to achieve the set goals and has

been demonstrated• Skilled counseling is the answer.• Act very close to desired change

Thank you !Thank you !