long duration breastfeeding natural, healthy—and in emergencies life saving one asia breastfeeding...
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Long Duration Breastfeeding
Natural, Healthy—and in EmergenciesLife Saving
One Asia Breastfeeding Partners ForumColombo, Sri Lanka
November 18-21, 2009
Keynote Address Presented by:Professor Michael Latham
Cornell UniversityIthaca, NY 14850, USA
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The Crisis of Malnutrition Among Underprivileged Families A hidden crisis contributing to half of all
young child deaths
A crisis that can only be solved by assuring children everywhere, with adequate food, health, and care
Food, health, and care – Breastfeeding contributes to all three
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2008 Lancet Series on
Maternal and Child Undernutrition Concluded:
Undernutrition (stunting, wasting, and intrauterine growth retardation) are responsible for:
2.2 MILLION DEATHS PER YEAR
Sub-optimum breastfeeding responsible for:
1.4 MILLION OF THESE DEATHS PER YEAR IN CHILDREN UNDER 5 YEARS OF AGE
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WHO/UNICEF: Global Strategy for Infant and Young Feeding (2003)
“As a global public health recommendation, infants should be exclusively breastfed for
the first 6 months of life…”
Thereafter, “…infants should receive nutritionally adequate and safe
complementary foods while breastfeeding for up to 2 years of age or beyond.”
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WHO/UNICEF: Global Strategy for Infant and Young Child Feeding (2003)
Breastfeeding is an unparalleled way of providing ideal food for the healthy growth
and development of infants; it is also an integral part of the reproductive process with important implications for the health
of mothers
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INEQUITY…
…in incomes, education, healthcare, etc is
THE MAJOR CAUSE OF HUNGER AND MALNUTRTION
The rich get richer (nations and people)The poor get poorer (in the North and South)
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Conceptual Framework of Causes of Malnutrition
Inadequateaccess to food
Inadequate care forchildren and women
Insufficient health services & unhealthy
environment
InadequateDietary Intake
Disease
Malnutrition
Resources and ControlHuman, economic and
organizational resources
BasicCauses
UnderlyingCauses
ImmediateCauses
Manifestation
Inadequate Education
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UnderweightModerate and Severe
(WHO)
WastedModerate and Severe
(NCHS/WHO)
South Asia41% 18%
Sub-Saharan Africa24% 9%
Nutritional Status of Children (0-59 months) in South Asia and Sub-Saharan Africa (UNICEF
2009)
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Percentage of Children 0-59 Months Underweight and Stunted1
Moderate and Severe Underweight (WHO)
Severe Underweight Moderate and Severe Stunting (WHO/NHCS)
Afghanistan 39 12 54
Bangladesh 46 - 36
India 46 - 38
Indonesia 28 9 -
Malaysia 8 1 -
Myanmar 32 7 94
Nepal 45 10 43
Pakistan 38 13 37
Sri Lanka 29 - 14
Thailand 9 0 12
Vietnam 20 5 36
1. UNICEF. The State of the World’s Children. 2009.
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Percentage of Children 0-59 Months with Moderate or Severe
WastingModerate and Severe
Wasting (NCHS/WHO)
Afghanistan 7
Bangladesh 16
India 19
Indonesia -
Malaysia -
Myanmar 9
Nepal 12
Pakistan 13
Sri Lanka 14
Thailand 4
Vietnam 8
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Infant Mortality Rate (under 12 months) and Under 5 Mortality Rate
Infant Mortality Rate Under 5 Mortality Rate
1990 2007 1990 2007
Afghanistan 168 165 260 257
Bangladesh 105 47 151 61
India 83 54 117 72
Indonesia 60 25 91 31
Malaysia 16 10 22 11
Myanmar 91 74 130 103
Nepal 99 43 142 55
Pakistan 102 73 132 90
Sri Lanka 26 17 32 21
Thailand 26 6 31 7
Vietnam 40 13 56 15
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Infant Mortality Rate (under 12 months) and Under 5 Mortality Rate
Infant Mortality Rate
Under 5 Mortality Rate
1990 2007 1990 2007
Bangladesh 105 47 151 61
India 83 54 117 72
Nepal 99 43 142 55
Pakistan 102 73 132 90
Sri Lanka 26 17 32 21
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Percentage of Children Under 6 Months of Age Exclusively Breastfed, and Still Breastfed at 20-23
Months Exclusively Breastfed
(<6 months)Still Breastfeeding
(20-23 months)
Afghanistan - 54
Bangladesh 37 89
India 46 77
Indonesia 40 59
Malaysia 29 12
Myanmar 15 67
Nepal 53 95
Pakistan 37 55
Sri Lanka 53 73
Thailand 5 19
Vietnam 17 23
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Deaths Attributable to Underweight
• 816,000 diarrhea deaths
• 1,043,000 pneumonia deaths
• 261,000 measles deaths
• 549,000 malaria deaths
• 154,000 PEM deaths (direct)
• 127,000deaths from perinatal conditions
• 3,727,000 deaths overall = 54% all child deaths
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Distribution of 11.6 million deaths among children less than 5 years old in all developing countries
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Anemia prevalence by global region, sex and age
0
10
20
30
40
50
60
70
Africa
Amer
icas*
E. Medit
E. Euro
pe
South A
sia
SE Asia
U.S.A
.
0-4 y
Women
*excludes North America
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US Institute of Medicine Recommendation
Human milk is a sufficient source of iron for the first 6 months of life, but foods with bioavailable iron, iron-fortified foods or a low-dose iron supplement should be provided at 6 months or earlier, if supplementary foods are introduced before that time.
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Immune Benefits of Breastmilk
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Impact on Diarrheal InfectionsPrevalence of diarrhea in infants under 2 mo in Peru in 1988 according to feeding pattern
Source: Victora C (1996)
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Impact on Respiratory InfectionsRisk of pneumonia in children under two years of age in two Brazilian site in 1993-5 according to type of milk
Source: Victora C (1996)
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Infant mortality associated with NOT breastfeeding (pooled data from Brazil, Pakistan, Philippines)
0
1
2
3
4
5
6
7
0-1 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo
Age
Od
ds
Rat
io
From: WHO Collaborative Team on the Role of Breastfeeding on the Prevention of Infant Mortality (2000)
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Feeding 6-24+ Month Old Children
Opportunity for the breastfeeding community
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Exclusive Breastfeeding for 6 Months It took 45 years of our involvement and
actions to finally get: WHO, UNICEF, pediatric societies and
governments of many countries to accept and advise: Exclusive Breastfeeding for 6 Months
In 2009, many countries, including those with a breastfeeding culture, only a minority of mothers exclusively breastfeed for 6 months.
But some real successes in increasing percentage of exclusive breastfeeding have been reported.
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WABA, IBFAN, La Leche League, ILCA and other breastfeeding allies, UNICEF, WHO, and countries:
Still have much work to do to greatly expand:
Percent of newborns put to breast immediately after birth
Percent exclusively breastfeeding for 6 months
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Improving
Breastfeeding Children 6-24+ Months of Age 1. Duration
Actions to increase the length of breastfeeding
2. Volume of Breastmilk Encouraging mothers at 6 months to introduce
other foods while maintaining high volumes of breastmilk to 24 months and beyond
3. Advise Mothers At each feeding, before offering
complementary foods, always breastfeed first
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Advantages of Long Duration, High Volume Breastfeeding Nutritional Birth spacing Economic Health (reduced infections) Psychological (caring) Agricultural Environmental Reduced breast, and other, cancers in the
mother Other
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Breastfeeding for 6 – 24+ Month Old Children There appear to be:
No indicators
No programs for maintaining or improving it
No guidance or guidelines
No social or political declarations on importance, nor on what to do about it
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Complementary Feeding for Children Breastfed from 6-24+ Months When continuing high volumes of
breastmilk… There is less need for high protein
commercially manufactured complementary foods
More likely that available family foods together with breastmilk will satisfy nutritional needs of baby
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Actions to Improve Breastfeeding for 6-24+ Month Old Children Protection
Code enforcement; prevention of actions that influence mothers to reduce duration, frequency, and volumes of breastmilk
Support Actions that assist mothers to breastfeed more and
longer; actions to make it easier for women who work away from home to continue breastfeeding; assist mothers with breastfeeding problems; etc
Promotion Education of community healthworkers, nurses, doctors,
and others; education of mothers, fathers, and families; government support and promotion
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Research Needed Lack of much good data on importance of
breastfeeding 6-24+ children 1. What common volumes of breastmilk are
provided at different ages in different groups?
2. What factors seem to positively influence higher volumes and longer duration?
3. What are negative influences? Time; women’s work, commercial influences, etc
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The Contribution of Breastmilk to Nutrient Requirement of Child 6-24 Months of Age Acceptance by UNICEF, WHO, Pediatric
Societies, etc., that 6 months of breastfeeding can provide 100% of nutrients for the infant
Assumption #1 Healthy, normal, well-nourished 6 month old
would be receiving 700-1000mL of breastmilk per day
Assumption #2 Healthy mothers are usually capable of
providing 500-850mL of breastmilk daily after their infant is 6 months of age
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ENERGY REQUIREMENTS FOR CHILD FROM 1-24 MONTHS OF AGE AND ENERGY CONTENT OF DIFFERENT DAILY AMOUNTS OF BREASTMILK
0.0
100.0
200.0
300.0
400.0
500.0
600.0
700.0
800.0
900.0
1000.0
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 23-24
Age (months)
Ener
gy (k
cal/d
ay)
1000mL
850mL
750mL
500mL
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PROTEIN REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND PROTEIN CONTENT OF DIFFERENT DAILY AMOUNTS OF BREASTMILK
0
2
4
6
8
10
12
14
16
18
20
0-6 7-12 13-24
Age (months)
Prot
ein (g
/day)
1000 mL
850 mL
750 mL
500 mL
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VITAMIN A REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND VITAMIN A CONTENT IN BREASTMILK
0
100
200
300
400
500
600
700
800
0-6 7-12 13-24
Age (months)
Vita
min
A (m
cg/d
ay)
1000 mL
850 mL
750 mL
500 mL
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VITAMIN C REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND VITAMIN C CONTENT IN BREASTMILK
0
10
20
30
40
50
60
0-6 7-12 13-24
Age (months)
Vitam
in C
(mg/
day)
1000 mL
850 mL
750 mL
500 mL
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CALCIUM REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND CALCIUM CONTENT IN BREASTMILK
0
100
200
300
400
500
600
0-6 7-12 13-24
Age (months)
Calci
um (m
g/da
y)
1000 mL
850 mL
750 mL
500 mL
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Percent of Nutrient Components of 750mL of Breastmilk
Age in Months0 – 6 7 – 12 13 – 24
Energy 100% 70.6% 57.9%
Protein 148% 123% 104%
Vitamin A 141% 113% 188%
Vitamin C 75.0% 60.0% 200%
Calcium 107% 83.3% 45.0%
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Variability in Nutrient Contribution Based on Nutritional Status of Mother 1. Only rather serious malnutrition for the
lactating woman results in her inability to produce reasonable quantities of breastmilk
2. Deficiencies in Vitamin A, Vitamin D, and Thiamine in diet of mother, substantially influences levels of these nutrients in breastmilk (much less so with other nutrients)
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Thiamine Deficiency
“Clinical infantile beriberi due to thiamine deficiency in mother is the only serious deficiency that regularly occurs in infants under 6 months of age receiving adequate quantities of
breastmilk (now extremely rare).”
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Breastmilk Potential Contributions to Nutritional Requirements of 6-24 Month Old Infants
Surprisingly there is not a great deal of information about amounts of breastmilk fed beyond 6 months in different societies and circumstances
Clearly 850mL of breastmilk would contribute very substantially to % of energy, protein, and micronutrient requirements from age 6-24 months
But also 200-500ml would still contribute useful amounts of nutrients
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US Institute of Medicine, National Academy of Sciences 1991 Statement Women are able to:
“Produce milk of sufficient quantity and quality to support growth and promote the health of infants even when the mother’s supply of nutrients is limited.”
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Infant Feeding In Emergencies Breastfeeding plays a vital role in
emergency response worldwide
THEREFORE
Important to advocate for active protection and support of breastfeeding before and during emergencies
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Infant Feeding In Emergencies If a tsunami swept all food off an island:
Who would be the first to die? Who would survive the longest?
Elderly Sick Pregnant women Other adults Older children Formula fed infants Breastfed infants
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Infant Feeding In Emergencies Those who would die first:
FORMULA-FED INFANTS
Those who would survive longest:
BREASTFED INFANTS
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Myths about Breastfeeding
Not true that:
Malnourished mothers cannot breastfeed
Stress prevents lactation
HIV-positive mothers should never breastfeed
Relactation impossibly difficult
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Free or Subsidized Supplies in Emergencies In general
Donated (free) or subsidized supplies of:
Breastmilk subsitutes (infant formula) Bottles and teats
should in most instances be avoided in emergency situations
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Examples of Emergencies
Floods in Botswana in 2006
96% of infants hospitalized for diarrhea were formula-fed
21% died
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Examples of Emergencies
Indonesian (Yogyakarta) Earthquake in 2006
25% receiving formula had diarrhea
12% not receiving formula had diarrhea
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Ready to Use Therapeutic Foods
(RUTFs)
Possibly a new threat to improved breastfeeding for
children 6-24+ months of age
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Definition of RUTFs (WHO, WFP, UNICEF)
“Ready to Use Therapeutic Foods (RUTFs) are high energy fortified, ready to eat foods, suitable for the treatment of children with severe acute malnutrition. These foods should be soft or crushable, and should be easy for young children to eat without preparation. At least half of the proteins contained in the foods should come from milk products.”
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3 Largest Users of RUTFs Worldwide UNICEF
MSF (Medecins sans Frontieres or Doctors without Borders)
Clinton Foundation (Mainly with U.S. PEPFAR funds for HIV/AIDS)
Note: An appropriate use for RUTF might be very young AIDS orphans
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Emerging Vocabulary
Ready-to-Use Food (RUF) fortified foods that do not require preparation, dilution or
refrigeration
Lipid-based nutrient supplements (LNS) RUF with majority of the energy provided by lipids
Ready-to-Use Therapeutic Food (RUTF) Plumpy’nut and local variations formulated to replace F-100
rehabilitation milk
Ready to Use Supplementary Food (RUSF) Nutributter , Plumpy’doz and local variations providing
supplemental energy + micronutrients
Community-based Therapeutic Care (CTC) Community-Management of Acute Malnutrition (CMAM)
outpatient / home-based nutritional rehabilitationSource: www.ilins.org
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The Bigger Policy Players Nutriset France
UN agencies (UNICEF, WFP, WHO)
Valid International / Valid Nutrition / Concern Worldwide
Medicins Sans Frontiers / Access to Essential Medicines
USAID FANTA Supply Chain Management Services (PEPFAR-related procurement)
Clinton Foundation Support development of national treatment guidelines expanded access to RUTF by purchasing supplies (33 countries by 2010) Promote market competition / encourage local production
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MSF – Niger Research 2006 - Cluster randomized study of 12
villages during famine season (JAMA 2009)
6 villages - 3-month distribution of 500 kcal/d RUTF (F-100) to all children age 6-59 mo with WAZ > 80% NCHS
6 villages no supplement
After 8 months 36% reduction wasting; 58% reduction severe wasting
No mortality effect
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RUTFs largely developed and promoted by Medecins Sans Frontieres (Doctors Without Borders)
A much admired organization providing doctors and healthcare in incredibly difficult areas and situations
Received well deserved Nobel Peace Prize in 1999
Medecins sans Frontieres (MSF)
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RUTFs effective way to treat Severe Acute Malnutrition (SAM) Including Kwashiorkor and Nutritional
Marasmus
Now being commercially made as “Plumpy’Nut” and other brands Often contains peanuts, milk powder, etc.
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Treatment of SAM Before RUTFsOur old (1960-?) treatment of severe protein energy
malnutrition (PEM) including Kwashiorkor and Nutritional Marasmus (now called SAM):
SCOM Mixture of Sugar, Casein, Oil, Milk (dry skim)
Advantages: Simple and available products Cheap In anorexic seriously ill child refusing food- easy to
give by intragastric tube Disadvantages:
Time to mix and variation greater than with RUTFs Also needed micronutrient supplementation
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RUTFs now being promoted also to prevent malnutrition in 6-24 month old children not just for therapy to cure SAM.
A huge leap to use RUTFs for prevention Is this medicalizing and commercializing young
child feeding??
A “medicine” replacing family foods and sometimes threatening breastfeeding
RUTFs for Prevention Not Treatment
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Concerns About Use of RUTFs for Prevention May undermine good breastfeeding in 6-
24+ month old children – already fragile
High costs of RUTFs relative to incomes of underprivileged families May violate WHO code or spirit of code
Program costs for RUTFs will reduce funding for other actions to reduce malnutrition and child deaths including promotion of breastfeeding
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Approximate Cost of Plumpy Nut (or other RUTF) 1 day for 1 child = Vitamin A or deworming to
last 6 months
1 week for 1 child = Immunization against measles that protects for years
1 month for 1 child = Bednets for 3 children to protect against malaria
1 year for 10 children = Cost of small rural clinic or keeping 10 girls in school for 1 year
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Recommendations UNICEF, WHO, FAO, WFP, and other
organizations including breastfeeding groups should meet to develop: Examples of guidelines for appropriate use of
RUTFs for prevention of malnutrition 1. Lactating women given RUTFs should always
breastfeed before offering RUTF 2. Make certain marketing and promotion of RUTFs
adheres to letter, and spirit, of WHO Code 3. Do no harm to
Breastfeeding Family feeding Local agriculture, etc
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MSF and Other Proponents of RUTFs Should Have as a First Priority:
Make certain that almost all hospitals, health clinics, and other community centers that treat childhood malnutrition have regular and adequate supplies of RUTFs
Why is this not the first priority of MSF et al?
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Consideration: Feed RUTFs to Mothers My suggestion:
When a lactating mother is given plumpy nut or other RUTF sufficient for total nutritional needs of 6-24 month old child
% of RUTF Fed:
Recommend: For Child For Mother
At 6 – 12 months 25% 75%At 12 – 18 months 50% 50%
At 18 – 24 months 75% 25%
This would help ensure good nutritional status of mother and child, and improve nutrient levels in breastmilk
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Agreements No disagreement about crisis of childhood
malnutrition No disagreement about 0 – 6 months exclusive
breastfeeding No disagreement that from 6 months on other
foods need to be introduced The debate: How much effort, funding, actions
should be devoted to… Family foods RUTFs (commercial complementary foods) Longer and more breastfeeding for 6-24+ month old
children
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Conclusions Longer duration of breastfeeding and greater
volume of breastmilk for children 6 – 24+ months of age is important for improved nutrition, health, etc. It is relatively neglected.
Commercial complementary foods, including RUTFs, are a feature of economic globalization and can constitute a threat to breastfeeding.
Greater actions are needed to protect, support, and promote more breastfeeding for children 6 – 24+ months of age.
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Thank you for listening!