1. UNICEF Programme Division Nutrition Section
Integrated Early Childhood Development at UNICEF: How does breastfeeding fit in?
UNICEF
Programme Division
Nutrition Section

2. Objectives -- The participant will:
Understand the general principles of I/ECD
Explore how to introduce breastfeeding in discussion of I/ECD
Explore how to introduce breastfeeding in discussions addressing the other 4 Strategic priorities
Understand the 3 sectors enhanced by LAM
Discuss the development of new “hooks” to increase interest in breastfeeding

3. Brainstorm Group 1: Breastfeeding in Other MTSP Strategies
Girl’s Education
Cognitive and psycho-social achievement highly associated with breastfeeding
Educate girls for important role as future mothers: “An educated girl educates her family and society about breastfeeding”

4. Brainstorm Group 2: Breastfeeding in Other MTSP Strategies
Breastfeeding provides first immune protection, and Vitamin A, among others, helps fight disease
Colostrum is the first immunisation
Immediate contact reduces illness by regulating temperature
Provides first doses of Vitamin A
Disease-free = sanitary, and prevents spread of bacteria
Visit is an opportunity to counsel on breastfeeding
Immunisation Plus

5. Brainstorm Group 3: Breastfeeding in Other MTSP Strategies
Strong nutrition link; EBF decreases transmission
Counselling is an opportunity to talk with mothers about breastfeeding
Use PMTCT sites to strengthen BFHI and to monitor Code
Lactation management to prevent and treat breast health problems reduces transmission
HIV/AIDS

6. Brainstorm Group 4: Breastfeeding in Other MTSP Strategies
Nurtured and breastfed children less likely to be deserted and abused
Refugee situations must know about the dangers of BMS
Violence in the home: mother-baby togetherness and support of relationship can protect baby
Calming effect of breastfeeding for frustrated mother
Food security: feeding mother is less expensive than artificial infant feeding , reducing financial stress, and
Birth spacing leads to better family health
Child Protection

7. The Lactational Amenorrhea Method (LAM):
Ask the mother, or advise her to ask herself these three questions:
YES
1. Have your menses returned?
4. The mother’s chance of pregnancy is increased. For continued protection, and to achieve a healthy three (3) years of child spacing, advise the mother to begin using a complementary family planning method and to continue breastfeeding for the child’s health, adding complementary feeding at about 6 months.. NO
2. Are you supplementing regularly or allowing long periods without breastfeeding, either day or night?
YES NO
YES
3. Is your baby more than six months old? NO
There is only a one to two percent chance of pregnancy at this time.
When the answer to one of these questions becomes YES....
Supports Breastfeeding, Birth Spacing and Timely Complementary Feeding

8. Try to develop a new “hook”!!
Select another sector (e.g., environment, food security, micronutrient programme, malaria, or other intervention area) that does not currently emphasize optimal breastfeeding
Consider what intervention or concept could be “socially marketed” that would “hook” those from this other discipline that are not currently supporting optimal breastfeeding into being supporters of breastfeeding.

9. Individual Work: Creative New Hooks(1)
Malaria
Bednet to keep baby safe and breastfed: “safe inside and out”
Environment
Breastfeeding has no waste products, no fuel, no commercial waste
Breastfeeding takes less water during shortages
Education
Psychosocial interaction that starts with breastfeeding leads to time spent with the child, story-telling and reading

10. Individual Work: Creative New Hooks(2)
Micro-enterprise
Breastfeeding women are reliable and willing to work from home
Credit Banks
Women who breastfeed have a track record of involvement and responsibility, and likely to pay back loan
Peacekeeping
Children who are breastfed are more compassionate to others
Others
Pharmaceuticals: With the increase in resistant pathogens, breastfeeding is important -- now more than ever.

11. Expand your Ideas through Teamwork!
I/ECD?
Hakuna matata...
When Faced with a Complex New “Vehicle”
Expand your Ideas through Teamwork!

13. Nutrition related MTSP target indicators
Reduction in anemia prevalence among women of reproductive age by 15%
> 60% of children receive appropriate home care for prevention and treatment of malnutrition
> 60% of pregnant women use adequate antenatal services

14. Focus of I/ECD
Integrated ECD is based on child’s rights principles and the life-cycle approach, developed to co-ordinate actions at different levels, aiming to improve:
Quality of family care
Family access to good basic services and adequate livelihoods
Community & policy environment needed to support the previous points.
General Goals:
Child Survival, Growth and Development

15. What is Integrated Early Childhood Development
What is Integrated Early Childhood Development? The Importance of the Mother-Child Dyad
Maternal nutrition for birth weight and maternal survival, early initiation of exclusive breastfeeding (EBF)
EBF, appropriate CF which includes responsive feeding, VitA, Birth spacing
Mother-child vs Child orientation, empowering caretaker to act and interact
If mom survives, the child is 3- 5 times more likely to survive
“A good start on life”
“Children under 3 y.o.”
“Support women’s health, nutrition, and well-being”
“Links to maternal health and survival”

16. Breastfeeding is the Heartbeat of Primary Health
Breastfeeding supports:
Nutrition
Oral Rehydration
Birth Spacing
and Fertility
Growth
and Development
Maternal Health
and Survival
Immunization
Reduced Cancer
and Chronic Disease
Logo, Breastfeeding Division, IRH

17. What is Optimal Breastfeeding?
Six months exclusive breastfeeding
Continued breastfeeding with appropriate complementary foods and feeding for 2 years and beyond
Related maternal nutrition and care
(Birth Interval of 3 years or more)

18. Breastfeeding -> Early Childhood Development
Increases in breastfeeding are associated with:
Decreased child desertion in hospitals
Best growth in first 6 months
Improved elements of neuro-psycho-motor development at age 1-2, and up to 12
Improved vision from a few months to years
Increased independence and parental trust
Increased intelligence quotient (IQ) assessed at ages 8 and 9 years; at age 18 years
Decreased infectious and chronic illness, and decreased impact of several metabolic conditions, supporting continued thriving

19. Breastfeeding -> Early Childhood Development
Increased adolescent perceptions of maternal caring
Higher reading comprehension, mathematical ability, and scholastic ability assessed during the period from 10 to 13 years;
Higher teacher ratings of reading and mathematics assessed at 8 and 12 years;
Higher levels of attainment in school leaving examinations
Contribution to birth intervals, allowing more attention to care and feeding, and maternal nutritional recovery:
Result: children are alive and thrive!

20. Current and Planned Interventions:
The Same Target Audience for All
FP(UNFPA)
ECD
LAM
BF/CF
ANTENATAL CARE
AT LEAST THREE YEARS
BIRTH SPACING VIA
FAMILY PLANNING USE
“Expanded Step Ten”
CODE
MNI CF
IMCI/CIMCI
IMM
CARE SEEKING
OPTIMAL AND RESPONSIVE
INFANT AND
YOUNG CHILD FEEDING
Expanded MPS/SM
BFHI
SAFE DELIVERY
ADEQUATE BIRTH WEIGHT
MPS
MNI
Malaria Presumptive Tx/Nets
ANTENATAL CARE

21. Current and Planned Interventions:
The Same Target Audience for All
FP(UNFPA)
ECD
LAM
BF/CF
ANTENATAL CARE
AT LEAST THREE YEARS
BIRTH SPACING VIA
FAMILY PLANNING USE
“Expanded Step Ten”
CODE
MNI CF
IMCI/CIMCI
IMM
CARE SEEKING
OPTIMAL AND RESPONSIVE
INFANT AND
YOUNG CHILD FEEDING
Expanded MPS/SM
BFHI
SAFE DELIVERY
ADEQUATE BIRTH WEIGHT
MPS
MNI
Malaria Presumptive Tx/Nets
ANTENATAL CARE

22. Birth Spacing Saves Children’s Lives: Relative risk of mortality with various birth intervals compared to a 3 year birth interval
Months Birth Interval

23. Approximate Annual Pregnancy Rate If:
Non-lactating = 60%
Lactating = 40%
Lactating and amenorrheic = 15%
Fully lactating and amenorrheic = 5%
Fully lactating, amenorrheic, <6 months postpartum = 2%
LAM users = <2%

24. Why does LAM have improved efficacy?
Slightly, but significantly, shorter intervals
Slightly, but significantly, more feeding episodes per day
Greater attention to night feeds
Dedication to breastfeeding patterns for fertility impact
Conclusion: Women who choose LAM will practice closer to optimal breastfeeding behaviors

25. Bellagio II CONFIRMED efficacy of LAM
SUGGESTED further study might enable “relaxing” the fully breastfeeding and 6 month requirements
DEFINED menses return as 2 consecutive days of bleeding or a vaginal bleed that the woman perceives of as a menses (after 8 weeks pp)
ENCOURAGED worldwide implementation fo LAM for all of its positive impacts

26. Breastfeeding vs LAM: Influencing other SectorsBF
LAM
use
FP
Uptake
BF
Patterns
 Birth Spacing
Fertility
 MTCT
Increased Child Health
and Survival

27. Objectives of this Session
Understand the general principles of I/ECD
Explore how to introduce breastfeeding in discussion of I/ECD
Explore how to introduce breastfeeding in discussions addressing the other 4 Strategic priorities
Understand the 3 sectors enhanced by LAM
Discuss the development of new “hooks” to increase interest in breastfeeding

28. Thank you
Asante-sana
Salamat po
Merci
Gracias
Danke
Spasibo
Abrigato
Barakallaofik

29. UNICEF Programme Division Nutrition Section
Infant and Young Child Nutrition and Related Maternal Issues: Targeting the Mother-Child Dyad - The Mother-Baby-Friendly Plan of Action
UNICEF
Programme Division
Nutrition Section

30. EXCLUSIVE BREASTFEEDING RATE (< 4 months), 1995-2000
Source: UNICEF, 2001

31. TRENDS IN BREASTFEEDING 1990-2000
Includes only countries with trend data
Percent
change 
+8%
+15%
+3%
+5%

32. (BFHI) Ten steps to successful breastfeeding
1.Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4.Help mothers initiate breastfeeding within one half-hour of birth.
5. Show mothers how to breastfeed and maintain lactation,even if they should be separated from their infants.

33. (BFHI) Ten steps to successful breastfeeding
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

34. The Baby-Friendly Hospital Initiative:
Vital...
A maternity facility can be designated when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and has implemented The 10 Steps.
Process controlled by national breastfeeding authorities, using Global Criteria. Implementation guides for the BFHI developed by UNICEF and WHO.
BFHI Part II provides the Global Criteria and outlines how to transform hospital practices.
Part IV and Part VI help to verify the ending of free and low-cost supplies of breastmilk substitutes. Additional BFHI Parts, including questionnaires used by external teams to assess facilities before Baby- Friendly designation, are available.

35. ...but is it sufficient? Baby Friendly and Beyond
Is it time to expand beyond BFHI?
If so, in what direction?
How can we support the World Fit for Children goals, the new UNICEF priorities, the war on HIV, while maintaining support and interest in best start for children: the caring of an empowered mother?
What specific components would extend the effort towards increased empowerment of women while maintaining the focus on the importance of optimal breastfeeding?
Is the idea of an "Expanded Step Ten," per se, attractive to you? “Mother-Child Dyad Initiative”? MBFAP?
Other ideas?

36. Timing of subsequent pregnancy by month postpartum and by breastfeeding status
IRH

37. Schema for Breastfeeding Definition
Full
Partial
Token
Exclusive
Almost
Exclusive
High
Medium
Low
Minimal
Full or Nearly Full Breastfeeding
Significant Fertility Impact
Low Partial/Token Breastfeeding
Minimal Fertility Impact
Labbok M and Krasovec K, 1989

38. Focus of Nutrition Interventions:
Main focus areas:
Ante-natal period is associated with infant growth, morbidity & mortality which makes maternal health and nutritional status essential
After birth, growth faltering needs to be prevented, and this should happen from early childhood onwards.

39. Complementary Feeding: Basic Principles
Maintaining Optimal Breastfeeding
Timing of initiation of CF and transition
Deciding on amount to give
Ensure viscosity
Preparing foods for ready digestion
Understanding Energy, Protein, and Micronutrient needs, and food choices
Learning and practicing interactive and supportive feeding behaviours

40. PMTCT, Code , BFHI and
I/ECD EMBFI Planning:
Four Stages in Implementing “Expanded Step Ten”: Expanded Mother/Baby Friendly Interventions

43. UNICEF Programme Division Nutrition Section
Integrated Early Childhood Development at UNICEF: Targeting the Mother-Child Dyad - Vital to MTSP Success
UNICEF
Programme Division
Nutrition Section

44. Bellagio I
“Women who are not using family planning, but who are fully or nearly fully breastfeeding and amenorrheic, are likely to experience a risk of pregnancy of less than 2% in the first 6 months after delivery”
Developed into LAM algorithm by group of FP and MCH program leaders at Georgetown, IRH
Studied in other formats by FHI and others

45. Return of Menses among Exclusively Breastfeeding Women: Cumulative Percent by Six-Month Life Table

46. Average Number of Feeds per Day by Month Postpartum* * * *
*p<0.05

47. Results of Studies on LAM Efficacy by 6 (or 9) Month Life Table%

48. Median duration of breastfeeding and lactational amenorrhea in selected countries
DHS, 1980s

49. Return of Ovulation During Lactation, by Feeding Pattern and Recurrence of a Menses-like Bleed
<60 days pp
> 60 days pp
Derived from Perez et al, 1979

50. Conclusions (1 of 2)
Interactive Breastfeeding and Responsive feeding are major elements in the life of the 0-3 year old
Early, Exclusive and Sustained Breastfeeding are shown responsive to intervention programs
ECD benefits inescapably from the presence of a living, health, and well-informed mother who is supported by her community - breastfeeding is empowering
If optimal infant and young child feeding is programmed, nearly all aspects of ECD are addressed and supported.

51. Conclusions (2 of 2) We have initiatives in place that support ECD
BFHI and Expanded BFHI
Enforcement of the Code of Marketing
New: Complementary Feeding in BF context
Nutrition Package of IMCI and Community IMCI
Making Pregnancy Safe/Safe Motherhood
Micronutrients programs - Vit A, Iodised salt, iron/folate, multi-vitamins
Others
Integrating their strengths by consistent messages at every contact will be the challenge
Targeting the maternal-child dyad may be a key to cross-sectoral integration