Complementary Feeding: the gap, causal analysis and possible solution in resource and knowledge poor situation

Dr. S.K. Roy

Chairman
Bangladesh Breastfeeding foundation

Introduction
Appropriate feeding practices are essential for the nutrition,growth,development and survival of infants and young children. These feeding practices, known collectively as Infant and young child feeding (IYCF) practices, include breastfeeding and complementary feeding.

Nutrition triangle (UNICEF)

Food Security

Breastfeeding Complementary Feeding

Disease Control

Caring Practices

Optimal Infant and Young Child Feeding practices by age of Child

0 0------------------------------------------------------------------------------------24 Age in month 6 24

Initiate BF within half hour of birth No prelacteal feeds Give colostrum Exclusive breastfeeding No bottle Feeding

Continue breastfeeding No bottle feeding

Feed CF 2-3 times a day plus snacks

Feed CF 3-4 times a day plus snacks

Dont start CF

Increase frequency, amount & variety of CF, including animal foods, fruits & legumes, Oils/Fat.

Significance
age-appropriate can have a major impact on child survival

19% per cent of all under-5 deaths in the developing world could be prevented by appropriate CF (Lancet 2003)
Even with optimum breastfeeding children will become stunted if they do not receive sufficient quantities of quality complementary foods after six months of age (Lancet 2008)

Malnutrition rates rise very steeply and peak in CF age (6-23 mo)
Malnutrition is related to inappropriate feeding practices

Develop a global partnership and multicultural collaboration

Provides Low cost , high quality food,thus Eradicate poverty, and hunger

Neurological Development, enhance later school performance.

Decreased milk industry waste, Ensure environmental sustainability

BF
CF
Promote gender equality, and empower women

Combat HIV, malaria, and other diseases Improve maternal health

Reduce infectious disease incidence and severity and thus Reduce child Mortality,

Current Situation of CF in South Asian Countries

Rate of Timely initiation of complementary feeding

(Introduction of any solid/semi solid food (age 6-7mo)

84.3 67.6 61.2 52.7 37.4

Feeding rate

BAN

IND

NEP

INDO

PAK

5 South Asian countries

Trend in Timely CF rate in Bangladesh according to birth order

Tim ely CF rate 2000 90 80 70 60 50 40 30 20 10 0 Tim ely CF rate 2004

76.3

76.3

76.3

23.5 12.2 14.1

First born

2nd -4th

5 or m ore

Timely CF rate in Bangladesh according to House hold wealth index

Timely CF rate 2000 90 80 70 60 50 40 30 20 10 0 Poorest Poorer Middle Richer Richest
12.7 4.5 19.6 24 20 66.9

Timely CF rate 2004

80.1 71.6 82.9

78.8

*p<0.01

Trend of nutritional status of <5 children 1996 to 2007 in Bangladesh

Stunting (height for age) 60 50 40 30 20 10 0 BDHS 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 18 10 13 16 55 56 45 48 43 36 48 46 Westing (wt for ht) Underweight (wt for age)

BDHS 2007

Trend in undernutrition in children aged 6-59 months in Bangladesh, 1985 to 2005 (NCHS)
Underweight 80 70 60 50 40 30 20 10 0 1985-86 1989-90 1992 1995-96 2000 2005 Stunting Wasting MUAC <125 mmm

UNICEF/BBS-2005

Trend in Infant and Childhood mortality, 1989 to 2006

Infant mortality 140 120 100 80 60 40 20 0 BDHS 198693 BDHS 199296 BDHS 199599 BDHS 19992003 BDHS 20032006 50 37 30 24 14 87 82 66 65 52 133 116 94 88 65 Child mortality <5 mortality

BDHS 2007

Prevalence of NS in children aged <5 in South Asian Country (NCHS)

Country
Afghanistan Bangladesh Bhutan India Maldives

Underweight
39 45 19 47 30

Stunting
54 40 40 46 25

Wasting
7 13 3 16 13

Nepal
Pakistan Sri Lanka

48
38 29

51
37 14

10
13 14

Gap and Causal analysis

The gaps in complementary feeding practices

Rate of Minimal acceptable diet and minimum meal frequency are not satisfactory in the south Asian countries Rate of receiving infant formula remains high Only 1 in 10 children are given Protein rich foods (meat , fish , poultry , and eggs) at 6-7 months of age Cereal based complementary food is more common or major source of energy Consumption of vitamin and mineral rich food items remain low Consumption of oil rich food items (fat , ghee, ,or butter) are low Milk products , such as cheese and yogurt are even less likely to be given to young children, and

Minimum Acceptable Diet (Four or more food groups)

Age (Months) Country 6-8 mo (%)
16.1 10.1 36.0 46.8

9-11 mo (%)
39.4 25.6 51.8 74.3

12-17 mo (%)

18-23 mo (%)
57.9 47.5 72.8 87.5

Bangladesh (2007) India (2005-06) Nepal (2006) Indonesia (2007)

48.4 42.9 74.8 84.5

Minimal Meal Frequency (Four or more times)

Age (Months) Country 6-8 mo (%)
59.7 21.6 63.9 3.4

9-11 mo (%)
74.0 15.6 73.7 7.7

12-17 mo (%)

18-23 mo (%)
93.5 28.9 90.7 13.5

Bangladesh (2007) India (2005-06) Nepal (2006) Indonesia (2007)

84.6 26.1 87.4 13.8

SAIFRN Complementary Feeding Analyses

Rate of receiving infant formula/other milk as complementary food(age 6-7 mo)

Infant formula
35 30 25 20 15 10

30.1%

15.4%
Infant formula

4.6%
5 0 Bangladesh Nepal Indonesia

Rate of protein rich food intake ( Meat, fish, poultry and Eggs)
Protein rich food
35

30.7
30

25

21.4
20 protein rich food 15

10.1
10

9.9

2.1
0 BAN INDO NEP PAK India

5 south Asian countries

Rate of giving protein rich diet in different age

40

35.2
35

30

30.7

25

20

6-7 month of age

16.3
15

6-9 month of age

10

10.1

9.9

10.6

0 BAN INDO NEP

Rate of vitamin A containing food intake(fruits and vegetables) (age 6-7 mo)
6-7 month of age
35

47.6
30

25

20

26
6-7 month of age

15

10

7.6
5

7.4

0 BAN INDO NEP

Rate of carbohydrate rich food intake

percentage of Carbohydrate rich food intake
90 80 70 60 50 40 30 20 10 0 Bangladesh Indonesia Nepal India

80.1

58.4 50.1 43.9

percentage of Carbohydrate rich food intake

Prevention of malnutrition using home based complementary Feeding

Intervention

Control

Roy et al 2008

What are needed now

Get the IYCF policy and programs implemented Resource allocation to make it happen in SA Ensure EIB in every household through MSG Mainstream IYCF in Heath systems Institutional capacity building on IYCF strategies Convergence to IYCF by all health programs Campaign and Advocacy at all levels with evidences

The Global Strategy of IYCF

Implementation of comprehensive policies by the Government

Full support for two years of breastfeeding or more

Promotion of timely, adequate, safe and appropriate complementary feeding

Guidance on IYCF in especially difficult circumstances

Legislation or suitable measures giving effect to the International Code

IYCF strategy in Bangladesh

The National Strategy outlines responsibilities of stakeholders and nine priority strategies: Legislation, policy, and standards: BMS marketing Code, maternity protection in the workplace, Codex standards for complementary foods, and national policies and plans Health system support: BFHI, mainstreaming and prioritization of IYCF activities, and knowledge and skills of health service providers Community-based support: community-based networks supportive of IYCF IYCF in exceptionally difficulty circumstances: enabling environments for appropriate IYCF practices in cases of HIV infection, emergencies, and malnutrition

Priority strategies for IYCF in Bangladesh

Legislation, policy and standards
Strategy 1: Code of marketing of breast-milk substitutes Strategy 2: Maternity protection in the workplace Strategy 3: Codex standards Strategy 4: National policies and plans

Continue..
Health system support
Strategy 5: Baby-friendly Hospital Initiative

Strategy 6: Mainstreaming & prioritization of IYCF activities

Strategy 7:Knowledge & skills of health service providers

Community based support

Strategy 8: Community based support for IYCF

Recommendation
For infants up to 6 months exclusive breast feeding should be encouraged and promoted as the most desirable feeding practice.

For older infants and older children, raising community awareness of the critical importance of the timely introduction of adequate quantities of safe nutritious complementary foods is key for improving nutrition Behavior change communication is very important for the success of complementary feeding.
Action should be taken by the mother, her family, her employer, community, and many others in support of breast feeding and complementary feeding practices to meet the nutritional needs of the child.

Community based nutrition programme components for development of Complementary feeding:

Menus of activities Support system Level of activity

1.food production 2. nutrition education 3. food sanitation/safety 4. antenatal care 5.GMP 6. breast feeding 7. other activities

1.Tranning 2.Funding 3.problem solving 4.supertion 5.plan/plans 6.implementation 7.planning and evaluation

1.facilitators 2.mobilizers 3.community level 4.household 5.individual

Feed your baby adequate and safe complementary feeding for healthy nation. -Thank you