Presentation on theme: "Why Breastfeeding? An Issue of Urgency in the Dynamic Global Situation"— Presentation transcript:
1 Why Breastfeeding? An Issue of Urgency in the Dynamic Global Situation Miriam H Labbok, MD, MPH, FACPM, IBCLC, FABM Professor and DirectorCAROLINABREASTFEEDINGINSTITUTEDEPARTMENT OFMATERNAL AND CHILD HEALTH
2 Objectives1. Better understand the contribution of breastfeeding to nutrition, health, development and survival2. Present what is known on the trends in breastfeeding practicesHighlight recent research, especially on issues that have contributed to policy and program change4. Review recommendations on infant feeding inthe context of HIV, emergencies, and other“hot” issues
3 Pop Quiz!!!!About how many children under age five will die in the world in the next 24 hours from preventable causes such as diarrhea, pneumonia and malaria, HIV?A. 5,000B. 10,000C. 15,000D. 30,000E. 50,000CBI Labbok, 2009With thanks to Sally Page Goertz for this subset of slides
4 The Question: Answer Of these 30,000, how many will die of HIV/AIDS? About 1000, orAbout 4% of preventable deathsCBI Labbok, 2009
5 How many of these deaths are preventable by Early and Exclusive Breastfeeding? Answer:About 4500, orAbout 15% of the preventable deathsCBI Labbok, 2009
6 Percent of U-5 Child Death Preventable By: 10/2008Academy of Breastfeeding Medicine
7 What is “Optimal” feeding? WHO/Unicef“infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health.Thereafter... infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.”-Breastfeeding alone is sufficient and uniquely suited for the first six months of life-While the US recommends BF to 1 year of life, this is not in conflict with the WHO recommendation-There is remaining controversy between the AAP breastfeeding committee’s recommendations and the AAP nutrition committee’s recommendations, which are still EBF for 4-6 months
8 Immediate postpartum initiation Exclusive breastfeeding What is Optimal Breastfeeding? Family security – the underpinnings and best start on health and nutritionImmediate postpartum initiationExclusive breastfeedingComplementary feeding and sustained breastfeedingBreastfeeding continues to provide essential micronutrients and energy.Active, responsive feedingAdaptation to family diet
9 Breastfeeding is the Heartbeat of Maternal/Infant Health Why Breastfeeding?Breastfeeding is the Heartbeatof Maternal/Infant HealthBreastfeeding supports:NutritionOral RehydrationFamily HealthGrowthand DevelopmentBirth Spacingand FertilityImmunization:Diarrhea/ Pneumonia/ Ear infectionsReduced MTCT of HIVReduced Cancerand Chronic DiseaseMaternal Healthand SurvivalLogo, Breastfeeding Division, IRH
10 “PROMOTION”IS NOT ENOUGH!ProtectionPromotionANDSupport
11 Everything you need to know about supporting breastfeeding clinically in one slide GUTMesentericlymph nodesBreastHypothalamusPituitaryOvaries-Comments?
12 Meta-analyses and Reviews 2007 Findings: Lack of breastfeeding significantly associated with an increase in the risk ofacute otitis media,non-specific gastroenteritis,severe lower respiratory tract infections,atopic dermatitis,asthma (young children),malnutrition,type 1 and 2 diabetes,childhood leukemia,increased blood pressuresudden infant death syndrome (SIDS), andnecrotizing enterocolitis.10/2008Academy of Breastfeeding Medicine
13 Immediate Postpartum Breastfeeding is also part of optimal feeding Decreased Maternal stressMezzacappa et al 2005Enhanced uterine involutionNegishi et al. 1999At three months potpartum, most significant variableDecreased blood lossBullough et al. 1989Increases neonatal survival at least 2.4-foldEdmond K et al. 2006, Darmstadt ,2005Appropriately delayed cord clampingChaparro, Dewey et al various, 2007/810/2008
14 If you need more reasons… Maternal HealthGrowth/SatietyIntelligence and upward mobilityBirth Spacing10/2008
15 What will the new growth chart do … Partial or no breastfeeding, 0-4 mos. associated with underweight at 12 mos.Piwoz EG, et al. (Peru)At 6 mo., BF infants were heavier and tallerVillalpando S, et al. (Mexico)Longitudinal study shows early formula spurt equalized by 2 yo, and no difference at adult height.Zadik Z, et al. (Israel)The impact of EBF for 3-5 mos. on growth was still detectable at 12 mos, even more significant in LBW.Arifeen SE, et al. 2001b. (Bangladesh)BW same in both groups, but study group with increased EBF had greater growth.Kramer MS, et al (Belarus)Increase from % EBF, at 6 months weight and length significantly higher in EBF.Froozani MD, et al. (Iran)-This impact on growth is the basis for the new WHO growth standards, which will be discussed in much greater detail later onCBI Labbok, 2009
16 Human milk was made for brain development Why should breastfeeding be associated with improved cognitive development?Human milk was made for brain developmentcomponents enhance brain developmentChildren learn with all their senses:Special smells and tastes of breastfeeding prepare infant for family foodsSeeing and smelling mother and hearing her heartbeatSeeing what she doesin all situationsNatural touch and othersensations
17 The Lactational Amenorrhea Method -- LAM Ask the mother, or advise her to ask herself, these three questions:1. Have your menses returned?4. The mother’s chance of pregnancy is increased. For continued protection,and to achieve a healthy three years of child spacing, advise the mother to begin using a complementary family planning method and to continue breastfeeding with complementary feeding after 6 months .YESNO2. Are you supplementing regularly or allowing long periods without breastfeeding, either day or night?YESYESNO3. Is your baby more than six months old?The LAM algorithm is a codification of the Bellagio Consensus Statement. It is designed to reinforce the that there are 3 criteria that are necessary for efficacy, that there is a fourth parameter(the need to emphasize the use of another method to achieve at least 3 years of child spacing, and clear guidance as to how one might help the new acceptor understands the method.The return of menses is the most important reflection of fertility return and, hence is the most important criteria to remember. However, since ovulation may occur during amenorrhea in partially breastfeeding women, the pattern of feeding becomes equally as important for successful child spacing with LAM. The third criteria, 6 months, was based on the fact that supplementation is recommended at that time. Results of several studies lead us to believe that LAM may be extended well beyond 6 months if LAM is successfully practiced for the first 6 months, and if the frequency and intensity of breastfeeding is maintained after some supplementary feedings are begun. One way to ensure the continued physiology of breastfeeding is to breastfeed the infant just prior to giving the supplementary feed; breastmilk remains a major, and in many countries, a vital source of nutrition for years of more.NOThere is only a one to two percent chance of pregnancy at this time.When the answer to one of these questions becomes YES....10/2008
18 Could there be more reasons to protect, promote and support breastfeeding? EpigeneticsCost savings for families and the nationReduced HIV transmission if EBF
19 A way to convince governments? Costs of Not Breastfeeding More than 15 billion dollars worldwide10s to 100s of millions in scarce import dollars in some countriesThousands of dollars per hospital in reduced need for nursing staff, formula and oxytocin substitutes10%-260% of annual minimum urban wage in selected countriesCost of mixed feeding twice that of EBF (India, Bhatnagar S, et al. )Increasing death and disease outbreaks
20 Academy of Breastfeeding Medicine Cumulative probability of HIV among 549 children born to HIV+ women Coutsoudis et al. AIDS 2001, 15:379-87Exclusively breastfed group ( ) is statistically significantly different from mixed fed ( ), but is not statistically significantly different from never breastfed ( )group until 15 months, controlling for 15 variables.10/2008Academy of Breastfeeding Medicine
21 Iliff P, Piwoz E et al. AIDS, 2005 Hazards Ratio for HIV Infection or Death from 6 weeks to 6, 12, and 18 months, by feeding patternControlled for Infant birth weight, and Maternal CD4 count, hemoglobin, death, marital status and Vitamin A treatmentDefinitiondeath or infection at 6 mo.death or infection at 12 mo.death or infection at 18 mo.p ValueEBFOnly BM1.0Pre-dominantBM & non-milk liquids2.42(0.71,8.18)2.36(1.00,5.57)1.73(0.84,3.52)p<0.05 at 12 moPartial/MixedBM & non-human milk &/or solid food3.03(0.95,9.69)(1.34,6.86)2.48(1.26,4.84)p<0.06 at 6 mo., p<0.008 at 12 and 18 mo.Iliff P, Piwoz E et al. AIDS, 200510/2008Academy of Breastfeeding Medicine
22 HIV-associated Findings Increased recognition of: The risks of not breastfeeding…Thior I et al, The Mashi Study, JAMA, August 16, 2006,Vol 296, No. 7 - Zidovudine plus BF or FFFormula feeding more effective in preventing postnatal HIV transmission, but BFing was associated with a lower mortality rate at 7 months.Both strategies had comparable HIV-free survival at 18 months.
23 HIV-associated Findings (cont’d) Fading rationale for replacement feeding…Kuhna L et al, AIDS 2005, Vol 19 No 15No difference found in mortality 12 months after delivery with assignment to short or long breastfeeding.
24 HIV-associated Findings (cont’d) And possible dangers of replacement feeding…Abiona T et al. MCN, 2006, 2, pp. 135–144Barriers to replacement feeding were:the high costs of replacement foods and fuel for cooking;an unreliable supply of electrical power;poor access to safe water and to storage facilities.
25 Replacement feeding is not necessarily easy or safe; It is potentially dangerous Most of the health workers had inadequate or incorrect knowledge for providing appropriate feeding counseling for HIV infected mothersAs part of the PMTCT programme, all mothers had received counselling regarding safe preparation of artificial feeds and cleaning of bottles. Nonetheless, there was unacceptably high levels of contamination (38-81%) and over-dilution (14-47%)
26 The Dangers of Replacement Feeding are Measurable Creek T et al, Not breastfeeding, hospitalization and survival during a diarrhea outbreak in Botswana, PEPFAR 2006Botswana: formula provided free by GoB.Not breastfeeding was associated with a 50-fold risk of emergency room visit.Not breastfeeding was associated with 8.5-fold increased risk of mortality (adjusted for SES, Age, and mother’s HIV status)
27 HIV and Infant Feeding: Framework for Priority Actions – Developed and Endorsed by Nine UN Agencies 1. Develop or revise (as appropriate) a comprehensive national infant and young child feeding policy, which includes HIV and infant feeding.2. Implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions.3. Intensify efforts to protect, promote and support appropriate infant and young child feeding practices in general, while recognizing HIV as one of a number of exceptionally difficult circumstances.4. Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies, and to successfully carry out their infant feeding decisions.5. Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings.
28 WHO Expert Meeting on HIV and Infant Feeding, October 2006 Disseminated 2007 Exclusive breastfeeding for 6 months is recommended for all women, and for HIV-infected women unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), in which case all breastfeeding should be avoided and infants should receive replacement feeding from birth.After 6 months, breastfeeding should be continued unless AFASS replacement feeding is available.Uganda
29 Updates on Trends, Policy, and Programs that Work
30 Trends: Percent of Children <6 mo old Exclusively Breastfed, ~1996 and ~ 2006 UNICEF, Trend analysis including 60% of the developing world populationCBI Labbok, 2009
31 No lack of IYCF policies and program designs that have be shown to work Innocenti DeclarationConvention on the Rights of the ChildGlobal Strategy for Infant and Young Child FeedingHIV and Infant Feeding: Framework for Priority ActionsMDGsCommunity-based Programs – C-IMCIBreastfeeding in emergencies
32 Persistent Myth: “We cannot achieve Exclusive Breastfeeding so why bother” Virtually every comprehensive or organized effort to increase exclusive breastfeeding has shown some level of successWhere programmes have shared with women both the risks and benefits of exclusively breastfeeding AND have offered skilled support, EBF increasesThis is true in villages and cities, emergencies and established setting, in HIV pandemic areas and elsewhere…
33 What Works? Four Pillars Government commitmentHealth System-- Education of health professionals-- Quality assurance= the Ten StepsLegal protection of breastfeedingWorkplace-- Paid leave and breaks-- Co-located child care5. DemandCreation
34 Innocenti Declaration 1990 Four operational targets Appoint a national breastfeeding coordinator with appropriate authority, and establish a multisectoral national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations, and health professional associationsSubnationalEmergencies
35 Breastfeeding-friendly efforts On WHO Website: 2. Ensure that every facility providing maternity services fully practices all the "Ten steps to successful breastfeeding" set out in the WHO/UNICEF statement on breastfeeding and maternity services:Breastfeeding-friendly effortsOn WHO Website:BFHI – new updated and expanded guidance available on lineWHO Textbook Chapter
36 Number of hospital practices in place predicts achievement of EBF Intention Helped you get started breastfeeding when you and your baby were ready (BFHI 4)Gave you free formula samples or offersShowed you how to position your baby to limit nipple soreness (BFHI 5)Encouraged you to feed ‘‘on demand’’ (BFHI 8)Told you about community breastfeeding support resources for ongoing help (BFHI 10)Provided formula or water to supplement your breastmilk (BFHI 6)Gave your baby a pacifier (BFHI 9)
37 Aggressive marketing continues Result can be catastrophic 3. Give effect to the principles and aim of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions in their entiretyAggressive marketing continuesResult can be catastrophic“through a Freedom of Information request at the FDA, … found algal- and fungal-based DHA/ARA have been linked to serious side effects such as virulent diarrhea and vomiting in infants consuming infant formula, many of whom required medical treatment and hospitalization.”
39 ILO Convention 183 and Recommendation 4. Enact imaginative legislation protecting the breastfeeding rights of working women and establish means for its enforcementILO Convention 183 and RecommendationArt. 10.1: "A woman shall be provided with the right to one or more daily breaks or a daily reduction of hours of work to breastfeed her child".Art. 10.2: "These breaks or the reduction of daily hours of work shall be counted as working time and remunerated accordingly".
40 And what can be done about the base of the pillars. 5 And what can be done about the base of the pillars? 5. Demand Creation in the CommunitySustainability depends on ongoing demand from the communityCould be built in many countries on the Rights Framework, Convention on the Rights of the ChildArticle 24(2e)- “measures to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding”-Other articles are related to women in the workplace and are equally important to emphasize in the workplace in order for women to be successful at breastfeeding:-Art. 2.1: "This Convention applies to all employed women, including those in atypical forms of dependent work": (all women sharing an employment relationship with an employer, including oral contracts; therefore, self-employed women and other independent women are not included, nor, in many cases, are women working for a family enterprise; "atypical" refers to part-time work, seasonal work, etc.);-Art. 4.1: "A woman to whom this Convention applies shall be entitled to a period of maternity leave of not less than 14 weeks" (instead of 12 in Convention 103).-Art. 4.4: "Maternity leave shall include a period of six weeks compulsory leave after childbirth";-Art. 6.3: "Where, under national law or practice, cash benefits paid with respect to leave are based on previous earnings, the amount of such benefits shall not be less than two-thirds of the woman's previous earnings";-Art. 8.2: "A woman is guaranteed the right to return to the same position or an equivalent position at the same rate at the end of her maternity leave"
41 Community-Level Strategies Lay/peer counselorsWomen’s groupsBehavior change communicationCounseling by health care providersc-IMCIBaby-friendly communitiesSocial marketing
42 IFE Policy basis – Operational Guidance Set of basic “dos” and “don’ts” for emergency relief staff and policy makersKey audience: all agencies working in emergency programsUN agenciesNGOs, national and internationaldonorsInteragency IFE Core Group
43 Interagency IFE Core Group Operational Guidance1. Endorse or Develop Policies2. Train Staff3. Coordinate Operations4. Assess and Monitor5. Implement Activities to Protect, Promote and Support Optimal Infant and Young Child Feeding6. Minimize Risks of Artificial FeedingInteragency IFE Core Group
44 Infant Feeding in Emergency Guidance: Updated and ready to go Infant Feeding in EmergenciesWorld Breastfeeding Week 2009:Be ready!
45 MILLENNIUM DEVELOPMENT GOALS End Poverty and HungerUniversal EducationGender EqualityChild HealthMaternal HealthCombat HIV/AIDSEnvironmental SustainabilityGlobal Partnership
46 Bottom line: Identify programme entry points for IYCF along the Intergenerational Lifecycle and build real protection, promotion and support into every activity COMPREHENSIVE ACTION IS NEEDED with adequate skills and knowledgeProgrammes for adolescents and students :Before and During Pregnancy:ChildMotherBirthMaternity practicesImmunisation sites, family planning clinics, other contacts
48 Feed the mother, breastfeed the child. Danke. Asante-sana. Tanke Feed the mother, breastfeed the child! Danke! Asante-sana! Tanke! Arigato! Ta! Obrigado! Grazie! Shieh-shieh! Gracias! Barakalo! Merci! Спасибо! Shokhrun! Shakrya! Toda-san!Thank you!!!
49 Major ReferencesMezzacappa ES, Kelsey RM, Katkin ES. Breast feeding, bottle feeding, and maternal autonomic responses to stress. J Psychosom Res Apr;58(4):Negishi H, Kishida T, Yamada H, Hirayama E, Mikuni M, Fujimoto S. Changes in uterine size after vaginal delivery and cesarean section determined by vaginal sonography in the puerperium. Arch Gynecol Obstet Nov;263(1-2):13-6Bullough CH, Msuku RS, Karonde L. Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants Lancet Sep 2;2(8662):522-5Edmond K, Zandoh C, Quigley M, Amenga-Etego S et al. Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality,Pediatrics 2006;117;Lancet Newborn Survival Series 2, Darmstadt G et al, Lancet 2005; 365: 977–88
50 Major References (continued) Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI Breastfeeding and the use of human milk. Pediatrics 2005 Feb;115(2):Labbok M, Clark D and A Goldman. Breastfeeding: maintaining an irreplaceable immunological resource, Nature Immunology. July 2004, 4(7):Labbok M. Breastfeeding: A Women’s Reproductive Right. In Keith L (ed), FIGO (International Federation of Gyn/OB) Annual Report, 2006, Int J Gynaecol Obstet Sep;94(3):277-86Ip S, Chung M, Raman G, ChewP, Magula N, DeVine D, Litt M, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment Number April; AHRQ Publication No. 07-E007.Horta et al. WHO. Long-term effects of Breastfeeding in Developing countries. WHO Geneva, 2007Fewtrell M. The long-term benefits of having been breast-fed. Current Paediatrics :97-103
51 Major References (continued) Global Strategy for Infant and Young Child Feeding. Available at:Innocenti Declaration. Available at:Innocenti Declaration Available at:ILO Convention 183 and Recommendation Available at:HIV and Infant feeding counselling: Knowledge, attitude and practice of health workers in Wesley Guild Hospital, Ilesa, Nigeria E A Adejuyigbe, A I Odebiyi MedGenMed Jul 11;6(3):MoOrE1068 [XV International AIDS Conference, Bangkok, Thailand, July ] Bacterial Contamination & Over-dilution of Commercial Infant Milk in South Africa:A Sub-Study of the National Prevention of Mother-to-Child-Transmission (PMTCT) Cohort Study, Erika Bergström [XV International AIDS Conference , Bangkok, Thailand, July ]