Successful Early Initiation and Exclusive Breastfeeding up to Six Months of Age “NUTRITIONAL STATUS OF <5 CHILDREN IS MOST SENSITIVE INDICATOR – DR.AMRITYA.SEN” Dr. Pradeep Dubey MD (Ped.), DCH. Cons. Developmental & Neuro Ped. “AADIGURU” Early Intervention Centre Wright Town - Jabalpur

India is epicenter of Childhood Mortality This is very famous slide of year 2003 which you might have seen thousand times. India continue to be epicenter of childhood mortality even in 2010. Worldwide distribution of child deaths Each dot represents 5000 deaths Lancet 2003 2

Childhood Mortality State of World’s Children 2008 9.7 million < 5 yrs deaths annually world over India 2.1 million (21%) India contribute to 21% of underfive child mortality world over. While contribution of neonatal deaths to underfive deaths is about 37% in rest of the world, in India it is 50%. Out of 2.1 million underfive deaths every year in India . One million deaths are in neonatal period. 1 million newborns die annually in India 3

Post Neonatal interventions - efficacy for reducing all cause of neonatal mortality Neonatal Resuscitation :6-42% Breastfeeding :55-87% Prevention and management of hypothermia :18-42% Kangaroo Mother Care (LBW):incidence of infection :51% (7-75%) The Bellagio Child Survival Series published in The Lancet in 2003 identified newborn survival as a priority, but lacking on information and action This data from Lancet neonatal survival series 2005 presents information regarding efficacy and costs of interventions for newborn care. Here we will focus on first four interventions:

Global and National Recommendations for Infant and Young Child Feeding Initiate breastfeeding within one hour of birth Exclusive breastfeeding for first 6 months of life Introduce nutritionally adequate and safe complementary foods after the infant reaches 6 months of age Continue to breastfeed for 2 years or beyond.

What is Exclusive Breastfeeding? Giving an infant only breastmilk No food or drink other than breastmilk— not even water No Ghutti/Honey etc.

Benefits to the Baby Complete food for the first six months Perfect nutrition Higher IQ Emotional bonding Prevents infections Prevents chronic diseases Easily digested

Benefits to the Mother Reduces post delivery bleeding and anemia Helps delay next pregnancy - LAM Protective effect against breast and ovarian cancer Helps to loose weight Emotional bonding Needs no preparation

Benefits to the Society Reduces absenteeism of mothers from work as they are less prone to disease. Economical Enhances Bonding

Underweight (-2sd) NFHS-3 First year is critical! Malnutrition strikes the most in infancy beginning in 3-4th month , 29-30 % at 6 months, goes up and peaks about 46% by 18 months, flat curve after that (NFHS 3). Brain development 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. 1 2 3 4 5 Underweight (-2sd) NFHS-3 Over 60 million In this slide you will see how first year is so critical – as among first 5 years of life shown as bars. The underweight bar is what begins in 3rd month of life and reaches about 29-30% by six months according to NFHS-3. After this it peaks by 18 months and then it almost flat – meaning thereby that action to ‘prevent under-nutrition’ should be a priority. Look at the brown line zooming through first – five years. This is for brain development and 70% brain develops during first year, 90% by end of 2 years .Finally, see out of approximately 20 Lac children who die annually( in India) around 14 lac die during first year of life. And rest later in four years. All this makes “first year” so critical. Years of life 10

Successful Breastfeeding… Exclusive breastfeeding for the first six months

U-5 deaths reduction by preventive Interventions Percent 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% Breastfeeding Complementary feeding Clean delivery Hib vaccine Clean water, sanitation, hygiene Zinc Vitamin A Breastfeeding is defined as exclusive breastfeeding for first 6 months and continued breastfeeding during 6-11 months Intervention Antenatal steroids Newborn temperature management Tetanus toxoid Antibiotics for PRM Measles vaccine Nivirapine and replacement feeding Insecticide-treated materials Antimalarial IPT in pregnancy Source: Jones et al. LANCET 2003;362:65-71

Successful Breastfeeding… Major Hurdles Lack of family support Lack of support by health professionals Commercial influence Feeling of not enough milk among women

Successful Breastfeeding… Important Do’s Initiate breastfeeding as early as possible within one hour of birth. Do not give the baby any prelacteal feeds No bottles, artificial teats or pacifier Breastfeeding on demand at least 8-10 times in a day and at night a Breastfeed in a correct position Build mother’s confidence to sustain good milk supply and alleviate feeling of not enough milk.

Successful Breastfeeding… Initiate Breastfeeding Within One Hour of Birth

Successful Breastfeeding… No Prelacteal Feeds Replace colostrum Reduce baby’s desire for breastfeeding Greater risk of infection Risk of intolerance, allergy

Successful Breastfeeding… No Bottles, Artificial Teats or Pacifiers for Breastfeeding Infants It lead to nipple confusion

Successful Breastfeeding… Breastfeeding in the Correct Position Milk producing glands Lactiferous canaliculi Lactiferous sinuses Myoepithelial tissue Adipose tissue Anatomy of the Breast

Successful Breastfeeding… Build Mother’s Confidence During prenatal period During antenatal Period During postnatal period

The Feeling of “Not Enough Milk” Not true. Just a perception Reinstate mother’s confidence Ensure frequent, effective suckling

Sensory Impulses from nipple Breastmilk Production The Prolactin reflex Sensory Impulses from nipple Prolactin in blood More prolactin secreted at night Secreted after feed to produce next feed Suppresses ovulation SLIDE-12(Production of breatsmilk - Prolactin reflex) We will now see how the breast milk is produced. As the baby suckles on the breast ..-click-.. it provides a sensory stimulus through nerve endings in the nipple to the anterior pituitary gland situated in the brain …-click-… resulting in the release of hormone called prolactin.. This hormone acts on glands in the breast for milk production. Thus, milk production is dependent on the sucking stimulus i.e. more the baby sucks more prolactin will be secreted and hence more milk will be produced …-click-… More prolactin is produced at night. Prolactin is helpful in producing next feed and in suppression of ovulation. Baby sucking

Sensory Impulses from nipple Breastmilk Transfer The Oxytocin reflex Sensory Impulses from nipple Oxytocin in blood SLIDE-12(Production of breatsmilk - Prolactin reflex) We will now see how the breast milk is produced. As the baby suckles on the breast ..-click-.. it provides a sensory stimulus through nerve endings in the nipple to the anterior pituitary gland situated in the brain …-click-… resulting in the release of hormone called prolactin.. This hormone acts on glands in the breast for milk production. Thus, milk production is dependent on the sucking stimulus i.e. more the baby sucks more prolactin will be secreted and hence more milk will be produced …-click-… More prolactin is produced at night. Prolactin is helpful in producing next feed and in suppression of ovulation. Works before or during feed to make milk flow Makes uterus contract Baby sucking

Breastmilk Transfer How does the mother’s confidence play part Pain Worry Stress Doubt Thinks lovingly of baby CONFIDENCE Sound of baby Sight of baby SLIDE-12(Production of breatsmilk - Prolactin reflex) We will now see how the breast milk is produced. As the baby suckles on the breast ..-click-.. it provides a sensory stimulus through nerve endings in the nipple to the anterior pituitary gland situated in the brain …-click-… resulting in the release of hormone called prolactin.. This hormone acts on glands in the breast for milk production. Thus, milk production is dependent on the sucking stimulus i.e. more the baby sucks more prolactin will be secreted and hence more milk will be produced …-click-… More prolactin is produced at night. Prolactin is helpful in producing next feed and in suppression of ovulation.

Feeding reflexes in the baby Rooting reflex Mother learns to position baby Sucking reflex Baby learns to take breast Swallowing reflex

Signs of Correct Attachment Mouth wide open Lower lip is turned outside Chin touching the breast Black part of the breast not visible below the lower lip Large black portion of breast and nipple including milk collecting ducts are inside baby’s mouth Tongue under the teat

Incorrect Sucking Position Mouth is not wide open Chin is away from the breast Baby is sucking only nipple Most black portion of the breast is outside the baby’s mouth Tongue away from the teat

Causes of Incorrect Attachment Use of feeding bottles. Leads to nipple confusion Inexperienced mother Functional difficulty with the mother or the baby Lack of skilled support

Exclusive Breastfeeding for First Six Months Conclusion Exclusive Breastfeeding for First Six Months Being Successful- Initiate breastfeeding as early as possible within one hour of birth. Do not give the baby any prelacteal feeds No bottles, artificial teats or pacifier Breastfeeding on demand at least 8-10 times in a day and at night a Breastfeed in a correct position Build mother’s confidence to sustain good milk supply and alleviate feeling of not enough milk.

Thanks