WHO's proposed global strategy for infant and young child feeding: a viewpoint.

The Global Strategy for Infant and Young Child Feeding is being developed by the WHO and is likely to be adopted as World Health Assembly Resolution in the month of May, 2002. The global strategy is built on Baby Friendly Hospital Initiative, the International Code of Marketing of Breast Milk Substitutes and the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. It emphasises the need for comprehensive national policies on infant and child health feeding including guidelines on ensuring appropriate feeding of infants and young children in exceptionally difficult circumstances and to ensure that all health services protect, promote and support breastfeeding exclusively for first 6 months and then timely and adequate complementary feeding with continued breastfeeding for two years or beyond. Thus the strategy is to improve nutritional status, growth and development, health and survival of infants and young children. It recognises that mothers should have adequate information and support within their families and communities should be free and should be free from commercial influence. The strategy mentions an effective feeding policy with some critical interventions as elaborated in this article.

Training in Baby Friendly Hospital Initiative.

The Baby Friendly Hospital Initiative (BFHI) was initiated in India with focus on large hospitals initially and then spread to many parts of India. 'Ten steps to successful breastfeeding' form the basis of BFHI of which step 2 regarding training is critical for the success of this programme. The duration of training should be at least for 18 hours, including at least 3 hours of clinical practice. Programme managers and policy makers should take training of health care staff rather seriously for achieving the real success in implementing the BFHI policies laid down in steps 3 to 10.

World Health Assembly recommends exclusive breastfeeding for first six months.

Exclusive breastfeeding means that the infant receives only breast milk (from his or her mother or a wet nurse or expressed breast milk) and no other liquids or complementary foods with the exception of undiluted drops or syrups consisting of vitamin and mineral supplements or medicines. During this period water is not permitted. The resolution (WHA 54.2) urges Member States to support exclusive breastfeeding for first six months as a global public health recommendation and to provide safe and appropriate complementary foods, with continued breastfeeding for up to two years or beyond. Breastfeeding Promotion Network of India (BPNI) has issued guidelines for breastfeeding and complementary feeding.

Detection and prevention of childhood disability with the help of Anganwadi workers.

OBJECTIVES: To evaluate the role of Anganwadi Workers (AWW) for detection and prevention of disability in children below 6 years of age. DESIGN: Cross sectional and longitudinal follow up. SETTING: Ten Anganwadi Centers in ICDS Urban Project. METHODS: Trained AWWs identified disabilities and instituted preventive measures like immunization and supplementary nutrition. Simultaneous independent verification by pediatricians. Repeat survey after 6 mo of follow-up. RESULTS: Amongst the 1545 children, AWW identified disability in 126 subjects which were verified in 118 cases by pediatricians. The disability rate was 7638 per 100,000 population. Visual, mental, orthopedic, speech and hearing disabilities rates were 4790, 2654, 583, 518 and 453 per 100,000 population, respectively. In the repeat survey, 35 of the 74 children with visual disability (mostly xerophthalmia), 4 of the 9 with orthopedic disability and 3 of the 7 with hearing disability could be managed satisfactorily. CONCLUSIONS: AWW can help in early detection and appropriate management of incipient and preventable childhood disabilities.

PIP: This study was conducted in the Integrated Child Development Services (ICDS) urban project of Gorakhpur in 10 randomly selected Anganwadi centers from October 1984 to September 1985. Anganwadi workers (AWW) were given in-service orientation and training to detect various types of disabilities in children below 6 years, 4 hours per day for 6 days at BRD Medical College. The study evaluated the role of AWWs in detecting and preventing disability in children younger than age 6 years. The trained AWWs identified disabilities and instituted preventive measures such as immunization and supplementary nutrition, together with the simultaneous independent verification by pediatricians, and a repeat survey after 6 months of follow-up. Among the 1545 children, the AWWs identified disability in 126 subjects which were verified in 118 cases by pediatricians. The disability rate was 7638 per 100,000 population. Visual, mental, orthopedic, speech, and hearing disabilities rates were 4790, 2654, 583, 518, and 453 per 100,000 population, respectively. In the repeat survey, 35 of the 74 children with visual disability (mainly xerophthalmia), 4 of the 9 with orthopedic disability, and 3 of the 7 with hearing disability could be managed satisfactorily. It is concluded that AWWs can help in the early detection and appropriate management of incipient and preventable childhood disabilities.

Growth patterns in breastfed babies during first six months of life.

Growth of exclusively breastfed 126 normal newborns in urban slums and those delivered at Nehru Hospital, Medical College, Gorakhpur were studied upto six months of age. The average weight of both boys and girls was almost equivalent to the 25th percentile of NCHS standard upto 3 months but fell below these standards thereafter. The average length in both boys and girls was between 25th and 50th percentile of NCHS data. The average head circumference in girls was between 25th and 50th percentile of NCHS data at all ages but in boys it was between 10th and 25th percentile at 4, 5 and 6 months of age. The average weight, length, head and chest circumference in both boys and girls were comparable to ICMR standards. The observations indicate that exclusive breastfeeding should be promoted for adequate growth of infants during first six months of life.

PIP: The study examined the growth patterns of breast-fed newborns from two populations of Gorakhpur, India, during January-December 1985: an urban slum population and others delivered at the B.R.D. Medical College. The sample included 52 community-delivered infants and 74 hospital-delivered infants weighing more than 2.5 kg at birth and without any congenital abnormalities or illness. Breast feeding was initiated by the newborns from the slum area after 2-3 days, while hospital-delivered infants were nursed immediately after delivery. Anthropometric measurements were taken within 24 hours of a hospital delivery and within a week after birth in slum community areas. Thereafter measurements were taken monthly for 6 months, and mothers were reinforced to continue breast feeding. Findings included only 76 infants were followed up for the entire 6 month period: 100% of the 52 community infants (31 boys and 21 girls) and only 32.4% (15 boys and 9 girls) of the hospital-delivered infants. The mean weight of infants was lower than the 50th percentile of the US National Center for Health Statistics (NCHS) data. Compared to the ICMR standard, weight differences for girls were significant only at 0 and 6 months of age, while for boys all differences between standards were significant. The mean weight of most infants was above the under-nutrition curve on the ICMR growth charts. Height was between the 25th and 50th percentile of the NCHS data. The ICMR values were comparable. The average head circumference was in the same percentiles as height for all female ages, but for boys at 4, 5, and 6 months the ranking was in the 10th to 25th percentile. Values were comparable to ICMR values. The gain in head circumference was comparable in 9 male and 13 female infants. Chest circumference was comparable to the only available ICMR values. The head/chest ratios showed normal growth of Indian children. The results confirmed the health advantages for growth in breast fed Indian children.

Anterior fontanel size.

Anterior fontanel size was determined in a cross-sectional study of 445 infants ranging in age from newborn period to 2 years. The mean anterior fontanel size in neonates was 3.37 +/- 0.61 cm which decreased to 0.37 +/- 0.06 cm in 24 months age group. The age of closure of anterior fontanel was 12, 18 and 24 months in 40%, 70.4% and 91.3%, respectively.

Breastfeeding in babies delivered by cesarean section.

One hundred mothers undergoing cesarean section and their infants were studied regarding various factors affecting the establishment of breastfeeding during their stay in hospital (mean = 11 +/- 3.6 days). Nearly two-thirds (65.7%) of mothers who underwent elective cesarean section, and 62.8% of mothers who received spinal anesthesia were breastfeeding exclusively; while only 53.8% mothers who had undergone an emergency cesarean section and 28.6% who received general anesthesia were exclusively breastfeeding their neonates. All 9 mothers who initiated breastfeeding within 12 h of the surgery were practicing total breastfeeding. In contrast only 5.8% of mothers who initiated breastfeeding after 96 hours, were exclusively breastfeeding their neonates. Total breastfeeding was more frequent (86.8%) in newborn infants who received prelacteal feeds by spoon as compared to those who received by feeding bottle (33.3%). Babies separated from the mothers in hospital were less likely (35.5%) to be on total breastfeeding as compared to those (68.1%) who were not separated from their mothers. This study suggests that for proper establishment of breastfeeding in mothers undergoing cesarean section an elective procedure under spinal anesthesia promotes, early initiation of breastfeeding. Early initiation of breastfeeding has highly significant correlation with establishment of breastfeeding while separation of babies from mothers discourages breastfeeding.

Breastfeeding status and marketing practices of baby food manufactured in nursing homes.

PIP: In January 1993 in Kanpur, India, a survey of 7 private nursing homes revealed that infant formula was given to most newborns (52.4%). The most common brands included Lactogen-I, Milk Care, Raptakos, Dexolac Special Care, and Lactodex. Staff at 5 nursing homes gave prelacteal feeds (water, glucose water, and infant formula) to newborns when they were separated from their mothers. Staff at only 2 nursing homes gave the newborn to the mother immediately after delivery. The longest period between delivery and giving the newborn to the mother was 24 hours. All but one of the nursing homes did not know about the government policy and the recent bill that bars free or low-cost infant formula supplies to hospitals. The administration of the nursing homes did not inform the procurement department, in writing, of the government policy. 4 nursing homes bought low-cost supplies of infant formula from the companies. The companies sold the infant formula to the nursing homes at a price 48.3% to 86.7% lower than the market price. Medical stores inside or outside the nursing homes sold the infant formula to parents at the other 3 homes. The nursing homes used, on average, 2-50 kg/month. Nestle (Lactogen-I) and Dalmia Industries (Milk Care) had a monopoly in infant formula in 4 and 3 nursing homes, respectively. Infant formula was in stock in 5 nursing homes. None of the nursing homes gave mothers free or low-cost infant formula at discharge. Lower than market price and increased number of calls to the hospitals and physicians by company personnel were marketing techniques used by the manufacturers to maintain market share. These results show that, despite government policy and the bill, hospitals continue to use infant formula. The government should use the mass media to increase awareness about its policy on infant foods and the concept of the Baby Friendly Hospital.^ieng

Breastfeeding and childhood cancer.

Total duration of breastfeeding and of exclusive breastfeeding was studied and compared in 99 childhood cancer cases and 90 controls. The difference between the average duration of breastfeeding in cases and controls was significant (p < 0.05), but when average duration of exclusive breastfeeding was compared in cases and controls the difference was highly significant (p < 0.001). In lymphoma cases and controls the difference between the average duration of breastfeeding was moderately significant (p < 0.01). However, when average duration of exclusive breastfeeding was compared in lymphoma cases and controls the difference was highly significant (p < 0.001). When other cancer groups and controls were compared with respect to their total duration of breastfeeding and duration of exclusive breastfeeding the differences when insignificant (p > 0.05). Cases and controls were not different with respect to their age, sex, birth year, birth order, age and educational status of mothers, smoking of fathers and socioeconomic status. However, a positive family history of cancer was obtained in 4 (4%) of cases whereas in controls it was obtained in only 1 (1.1%).

PIP: Between April 1991 and June 1992 in India, physicians compared data on 99 childhood cancer cases with data on 90 sex, age, and hospital matched controls to examine the relationship between duration of total breast feeding and exclusive breast feeding and childhood cancer. Most of the children were patients at G.S.V.M. Medical College in Kanpur or at K.G. Medical College in Lucknow. Cases and controls were essentially the same in respect to birth order, age and educational status of mothers, smoking of fathers, and socioeconomic status. 65.7% of cases had leukemia. The duration of total breast feeding was significantly longer for controls than cases (10 months vs. 8 months; p .05). The difference between mean duration of exclusive breast feeding between mean duration of exclusive breast feeding between cases and controls was significant (4.6 months vs. 3.2 months; p .001). Controls were more likely to have undergone a longer duration of total breast feeding and exclusive breast feeding than were lymphoma cases (10 months vs. 6.15 months; p .01 and 4.6 months vs. 3 months; p .001, respectively). 58% of lymphoma cases had non-Hodgkins lymphoma. When the researchers compared other cancer groups and controls, no significant difference between the 2 groups existed in respect to total breast feeding and exclusive breast feeding. These results suggest that breast feeding has a protective effect against childhood cancer. Further, they indicate that exclusive breast feeding provides more beneficial immunological effects than breast feeding supplemented by artificial feeding. The high rate of breast feeding in India may explain the low incidence of childhood cancer in India (e.g., around 6/100,000 vs. 18/100,000 in Israel).

Lactation failure.

Seventy five mothers with lactation failure were studied, whose less than 4-month-old babies were admitted to the hospital. Partial lactational failure (94.7%) was noted more often than complete lactational failure (5.3%). Initiation of breastfeeding was delayed for 2 to 5 days usually for traditional reasons (77.3%) and because the mothers felt that the milk output was inadequate (92%). The various causes of lactation failure were determined and the relationship to various factors was analyzed. The commonest cause of lactation failure was insufficient milk or no milk (80%). The age, parity, education, socio-economic status, religion, family structure and urban vs rural status of mother--all had a bearing on the occurrence of lactation failure. An attempt was made to relactate all these mothers. The outcome was successful in 69.3 cases and failed in only 4% cases. In 26.7% cases, we cannot predict the outcome as the mothers hospital stay was very brief with no follow up.

PIP: A total of 75 mothers whose babies under 4 months old were hospitalized with lactation failure were studied. The age of the mothers varied from 16 years to 40 years with a mean of 23.7 years. 50 (66.7%) of the mothers were from the urban areas. 43 (57.3%) of them were primipara and 61 (81.3%) were Hindus. All the mothers given prelacteal feeds comprising water, water with sugar or glucose, milk (goat, cow, or milk powder) to their babies. The commonest cause of lactation failure with insufficient milk or no milk (80%). The age, parity, education, socioeconomic status, religion, family structure, and urban vs. rural residence of mother had a bearing on the occurrence of lactation failure. The initiation of breast feeding was delayed for 2-5 days usually for traditional reasons (77.3%) and because the mothers felt that the milk output was inadequate (92%). Only 4 (5.3%) mothers had complete lactation failure and practiced exclusive top feeding. Of the 71 (94.7%) mothers with partial lactation failure, 41 (54.7%) were giving frequent breast feeds while 30 (40%) were breast feeding occasionally. Relactation was attempted in all cases. Mothers have been motivated to breast feed and were provided adequate rest, nutrition, and psychological support. If lactation was still not established, then metoclopramide was given orally in the 8-hourly dosage of 10 mg for 10 days. If this also failed, nursing supplementer was tried. The relactation attempt was successful in 49 (69.3%) partial and 3 (7.5%) complete lactation failure cases. Relactation failed in 22 (30.7%) mothers with partial lactation failure and 1 (2.5%) mother with complete lactation failure. (26.7%) mothers with partial lactation failure were lost to follow up. Out of 4 cases of complete lactation failure, 1 had severe anemia with hypoproteinemia, the 2nd developed intense dislike of her baby at birth, the 3rd had tuberculosis and was advised not to breast feed, and in the 4th case the mother stopped breast feeding completely because she felt that her milk was unsuitable.

Prevalence of HBsAg & anti-HBs in children & strategy suggested for immunisation in India.

The prevalence of HBsAg and anti-HBs was studied in sera from 982 children of different age groups below 5 yr. HBsAg was detected in 0.9, 2.3, 4.1, 2.3 and 1.6 per cent children of 0-1, 2-6, 7-12, 13-36 and 37-60 months age groups respectively. Anti-HBs in these five groups was noted in 17.0, 12.9, 18.4, 14.2 and 13.7 per cent children, respectively. The findings suggest that the carrier pool is built up in the preschool age group, particularly, below the age of 6 months. Perinatal transmission and the relative role of transplacental need re-evaluation. Cost analysis does not permit inclusion of HBV in the Expanded Programme of Immunisation.

Hepatitis B virus infection and its transmission in preschool children.

In the present study, 2.5% of 367 preschool children has HBsAg positivity. Of 11 mothers who were HBsAg positive during the third trimester of pregnancy, 4 had babies (36.4%) who developed HBsAg positivity by 2.5-3 months of age (vertical transmission). Two babies born of HBsAg negative mothers, with history of jaundice during first trimester, were HBsAg negative. All the relatives of HBsAg positive cases screened were negative for HBsAg.

Poliomyelitis with special reference to immunization status.

One hundred ninety one children below 5 years of age suffering from poliomyelitis were analyzed to find out the immunization status and its correlation with the incidence of poliomyelitis. Effects of age, sex, immunization status and seasonal variation on the morbidity and mortality status were studied. The maximum number of cases were admitted during the months of July (23.6%) and August (23.1%). Of 191 cases, 143 (74.9%) had no immunization and 48 (25.1%) were partially immunized. A total of 155 (81.2%) cases had spinal polio, 23 (12.01%) bulbo-spinal polio, and 13 had (6.8%) bulbar polio. Serious illness (bulbospinal and bulbar type) was more in partially immunized children (25%) as compared to unimmunized children (16.8%). The mortality rate was more than two times higher in the partially immunized (29.6%) as compared to unimmunized children (11.2%). The possible explanation for high mortality in partially immunized children could be due to the adverse effect of OPV which has not been studied so far.