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Working Group on Breastfeeding and Complementary Feedingheld during the SCN's 34th Session, Sunday 25 February 2007 (10:00-3:30) and on Wed. Feb. 28 from 8:30-10:30, Rome. Chair: David Clark (UNICEF) Agenda (with links to the presentation materials) Emergency Nutrition Network (ENN) Infant and Young Child Feeding in Emergencies – Operational Guidance for Emergency Relief Staff and Policy-Makers. Available in English, Portuguese, French and Spanish. HIV and infant feeding update. Early breastfeeding cessation was associated with increased morbidity and mortality in HIV exposed infants. The provision of free infant formula does not necessarily lead to better HIV-free survival compared to exclusive breastfeeding. Additionally, even when formula is provided free, it is often not available at all times due to supply chain difficulties or lack of access to clinics. Concern was also raised about the sustainability of supplying formula for country wide programs such as in Botswana. Longer durations of exclusive breastfeeding have been achieved in HIV-infected and HIV-uninfected mothers given consistent messages and frequent, high quality counselling. The discussion section included concerns about practical experience with AFASS, with many health workers feeling it is difficult to implement. Others expressed the difficulty of counseling the mother about stopping breastfeeding at 6 months when no other appropriate milk or other animal products are available. Some suggested that delaying introduction of other foods may not be as dangerous as stopping breastfeeding, while others expressed concern that it is a real shift to promote the delayed introduction of foods beyond the age of six months. Questions were raised about at what age mixed foods are the most dangerous for infants, but data have only been reported for infants under 6 months of age. Implementation of 2006 working group recommendations: Improving communication among members of the WG. Ted Greiner mentioned a WABA list serve he conducts on HIV and infant feeding. Those who are interested should email him (tgreiner@path-dc.org) and he will add names to the list serve. It is a Yahoo group where there are documents on file and PowerPoint presentations on HIV and infant feeding topics that can be downloaded. This list serve is only for relay of information and does not allow comments, thus members will only receive emails when new information is posted. Celebration of 25th Anniversary of the Code and World Breastfeeding week: The 2006 theme of World Breastfeeding Week was “Code watch: 25 years of protecting breastfeeding. Lida Lhotska, on behalf of WABA, described the materials that were made available and distributed to assist planning of the celebration of WBW, and reported that the website http://worldbreastfeedingweek.org/ gives information on activities from over 30 countries, not just in terms of advocacy, but also on the organization of community activities and trainings. In the context of celebrating WBW in Geneva, IBFAN-GIFA organised a ceremony to commemorate two important events:
Another activity to celebrate the 25th anniversary of the Code was the carrying out of “Marketing Snapshots”. Coordinated and vetted by IBFAN ICDC, with technical support from WABA. The Marketing Snapshot project was posted on the WBW website. Called “Look what they are doing” it provided an avenue for WBW celebrants to report how companies were marketing their products in their respective neighbourhood. A total of 124 reports were received from 15 countries, the low number of countries reporting perhaps suggesting that few people understand issues related to marketing and the code. Lida Lhotska also announced that IBFAN has a modular 3-day training on the Code, intended to build awareness of the need for Code implementation and enforcement. The modules, handouts, charts and overheads are available for purchase on request from the International Code Documentation Center. Last year at the SCN, the Innocenti Declaration of 2005 was endorsed by SCN. UNICEF’s Innocenti Research Center in Florence, Italy developed posters entitled “Breastfeeding: the essence of life” in three languages (English, French and Spanish) and brochures containing the 2005 Declaration and information on breastfeeding. These are available in 7 languages (English, French, Spanish, Russian, Chinese, Arabic and Italian). The Declaration was also welcomed by the 2006 WHA. UNICEF was asked to inform its Executive Board about the Declaration and invite the Board to endorse it, similarly to what was done with the 1991 Innocenti Declaration. Rolling out of new Growth Standards: Kay Dewey and Randa Saadeh (WHO) discussed the new Growth Standards and how WHO has been expanding their use. The new growth standards are based on the breastfed infant as the normative model for child growth. The new standards are based on longitudinal data from birth to 2 years of age and cross-sectional data from 1.5 to 5 yrs of age in six countries. Weight for age, weight for height, height for age, and BMI for age curves are now available from WHO. Other anthropometric data were also collected (skinfold thickness and arm circumference) and these standards have been tested in Spain and are due to be released soon. Growth velocity standards will be available soon. These will provide data on the amount of weight or height to be gained during defined measurement intervals. Two background documents were commissioned on 1) technical and 2) implementation issues using growth velocity standards. A technical meeting will be held in March, 2007 in Geneva. Future steps are to develop fetal growth standards using a prescriptive approach; this is a joint effort by Oxford and WHO. Postpartum maternal weight change reference data will be developed based on data from the 6 countries. India, Indonesia, some African and many Latin American countries have now adopted the new standards. The US and many European countries have not made a decision yet and their use is still under consideration. Where countries have their own standards, it was hard to convince them that well nourished children grow similarly during childhood. The studies included in the new growth standards found no significant differences in height across sites illustrating that there are no ethnic differences in early linear growth. The IMCI charts are being revised. Reporting of data on DHS and MICS will use new standards; which will change the estimates of stunting (rates will go up); rates of underweight will go up in some age groups; overweight will go up at 2-3 years of age. The new Lancet series of 5 papers on nutrition interventions and their potential impacts will use the new standards to show levels of malnutrition. There will be training of trainers in how to use the new standards (Cairo, Bolivia, South Africa, Indonesia, Nicaragua, Malaysia). The training course is available at http://www.who.int/childgrowth/training/en/index.html. Revitalization of BFHI The 59th World Health Assembly mandated the revitalization of the Baby Friendly Hospital Initiative (WHA59.21). Although there are about 20,000 Baby Friendly hospitals accredited world wide, there has been some slippage and rates of exclusive breastfeeding worldwide are relatively low at 38%. Randa Saadeh of WHO discussed the need for increased support by governments and enhanced supervision and improved counseling skills and coverage by health-care workers. The training materials for the BFHI have now been updated and expanded with the new package (available on the UNICEF http://www.unicef.org/nutrition/index_24850.html and WHO websites http://www.who.int/nutrition/topics/bfhi/en/index.html) including: Section 1: Background and Implementation The new assessment tools have been revised to reflect current evidence and added emphasis on the Code and support for non-breastfeeding mothers. Now hospitals need to implement the Code to be considered Baby Friendly. The assessment tools have also been revised to include optional "modules" on:
The external assessment manual is only available on request because only assessors can have it. The package will be available in all 5 UN languages (English, Spanish, French, Arabic, Chinese). There have been selected enhancements to the Ten Steps including the following:
There was a change in interpretation of Step 4 from: "Help mothers initiate breastfeeding within a half-hour of birth" to "Place babies in skin-to-skin contact with their mother immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed."
WHO is currently updating the 'Scientific basis for the Ten Steps'. There will be a training in San Diego on the new material in the summer 2007. Emphasis was placed on the need to extend BFHI to the community level (BFCI), in Primary health care settings, to obstetricians and care within neonatal intensive care units. BFHI expansion and revitalization should be reported on at the working group next year. In the discussion, WHO was requested to clarify the criteria regarding exclusive breastfeeding at discharge. As currently worded, the criteria would theoretically allow a hospital with no exclusive breastfeeding at discharge to become Baby-Friendly. WHO has received this comment from other parties already and is looking into the question. Task force on HIV and Complementary Feeding: Judy Canahuati reported that the Working Group on Nutrition in Emergencies is working on a module on HIV and complementary feeding. Kay Dewey to find out about it. World Breastfeeding Week 2007 –Theme for 2007. Breastfeeding: The 1st Hour - Save ONE million babies! Arun Gupta reported on the theme for World Breastfeeding week 2007 which is based on extrapolations from the study conducted among 10,000 infants in rural Ghana by Edmonds et al (Pediatrics 2006 116:380-86) which found benefits of both exclusive breastfeeding and early initiation of breastfeeding on improving neonatal survival. Based on their analyses,
They were able to locate information in 38 out of 60 high mortality countries which had data on timing of initiation of breastfeeding. The average proportion initiating breastfeeding within the first hour was only 36%. From these analyses, it is predicted that 250,000 neonatal lives could be saved in India alone and 1 million world wide out of 4 million neonatal deaths. IYCN: USAID Infant and young child nutrition project: Rae Galloway reported on the new IYCN project funded by USAID. This is a jointly conducted 5 year $46 million ceiling project. Partners include Path, Care, Manoff and University Research Corporation and many affiliated groups. The purpose of the project is to improve Infant and young child Nutrition, increase HIV survival and improve maternal nutrition. They want to illustrate cost effective interventions for breastfeeding, complementary feeding, maternal nutrition and improved caring practices. They will also work with public-private partnerships for the development of high quality complementary foods. World Breastfeeding Trends initiative: Arun Gupta discussed the World
Breastfeeding Trends Initiative, which tracks implementation of global strategy
on infant and young child feeding. Its goals are Forums were held in Bangladesh, Nepal, and Afghanistan, 2004-2006. Countries in Latin America and the Caribbean will start in 2009. Results of the South Asia initiative are available on the web at http://worldbreastfeedingtrends.org/. The initiative uses assessments at country level of the State of World’s Breastfeeding. Country report cards and action plans have been prepared for 8 South-Asian countries. It is part of the IBFAN Asia Pacific Strategic Plan 2003-2008 to support and achieve the goals of the Global Strategy for Infant and Young Child Feeding. The impact of this effort has been:
Complementary Feeding: what works? A systematic review of the literature Kay Dewey gave a presentation summarizing a review written with Seth Adu-Afarwuah on the efficacy and effectiveness of complementary feeding interventions. This review was supported by the Mainstreaming Nutrition Initiative with funding from the World Bank and it generally focused on reports from 1996-2006. The interventions were divided into the following categories:
There were 29 efficacy trials and 13 effectiveness trials and program reports, several unpublished. Some programs feed into more than one category. The review assessed the impact of these interventions of child growth, micronutrient status, morbidity, and child development. Impacts on growth were limited, but improvements in weight seem to be related to energy intake, while improvements in length may be related to other factors. For example, in Ghana, the impact on weight gain was partially explained by increased energy intake, but the impact on length gain was related to a change in plasma fatty acid profile. The review found that increasing energy density may be effective when the traditional complementary food has low energy density and infants are unable to compensate by increasing the volume of food consumed or feeding frequency. Otherwise, such interventions may not increase energy intake, and thus would have no impact on growth. Increasing energy intake from complementary foods may have a negative impact on intake of breastmilk, which would be another reason for the lack of impact seen with some of these interventions. Micronutrient fortification alone has little effect on growth, except for a relatively large study in India in which many children were stunted at baseline and the fortified product resulted in reduced morbidity. Few other studies had adequate sample size to evaluate impacts on morbidity or mortality. Very few studies evaluated child development but there were promising results using specially designed fortified milk-based (India) or fat-based (Ghana) complementary foods. Future evaluations of complementary feeding interventions should include assessments of child development, which may be a more sensitive indicator than growth. Complementary feeding interventions that included fortification were most successful in improving micronutrient status. The results of the review suggest that it is very difficult to achieve adequate Fe intake from local foods without fortification, especially at 6-12 months. It is possible to achieve adequate Zn and Vit A intakes from local foods, but it requires careful attention to dietary choices. Fortification can help ensure Zn and Vit A intakes when nutrient-rich local foods are costly or unavailable (e.g. seasonally). Improved iron intake due to fortification (commercial or home-based) was associated with a reduction of 13-21 percentage points in prevalence of anemia. However, there was little or no impact of fortification on plasma zinc – perhaps due to low absorption on of zinc in the fortified food. Results were mixed regarding fortification with Vit A, with a positive impact seen in several studies but not others, perhaps due to vitamin A supplementation programs masking benefits of fortification. The review concluded that educational approaches can be effective, but in many situations a greater impact may be seen when they are combined with home-fortification or provision of fortified foods. To be most cost-effective and avoid displacement of breast milk, the amount of food provided should be modest: no more than 200 kcal/d at 6-12 mo. The biggest challenge for complementary feeding interventions is going to scale with a combination of the most cost-effective components, while assuring adequate delivery and sustainability. TIPS methodology – the Afghanistan experience: Charlotte Dufour discussed the use of Trials of Improved Practices to improve infant and young child feeding in Afghanistan. She discussed the need to negotiate with mothers about small changes they could make to infant feeding practices, and emphasized the difficulties in mothers providing appropriate care given early age of childbearing and high fertility rates. Others described the amount of training and time that is needed to improve heath worker practices concerning negotiating with mothers rather than lecturing them about improved child feeding. It was also mentioned that where improvements have been seen in child feeding, the health worker to mother ratio is much higher than normally seen (for example in Thailand there was 1 worker for 20 households compared to a ratio of 1/1200 in Bangladesh, so that workers there have little time to deal with each mother. WHO has a three day counseling course on complementary feeding to train trainers on the guiding principles of IYCF. The need for new Indicators of complementary feeding was discussed and the use of two new indicators is being currently explored: dietary quality and feeding frequency. Dietary quality is being assessed using food group diversity (among 6-24 month old infants, both breastfed and not breastfed). The assessment is trying to identify poor or good dietary quality. Information to measure these issues is now included in DHS and MICS so soon there will be country level data to assess the new indicators of complementary feeding. Recommendations
Workplan
ECHUI The Working Group provided the Secretariat with comments on the September draft of the ECHUI Global Framework and was disappointed to notice that many of its concern’s were not incorporated into the latest version. The Working Group requests that the authors revisit these comments and incorporate them into the Framework. |
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