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 !