Why ensure exclusive breastfeeding for all babies?

Arun Gupta

05 August 2004

In February 2003, researchers from several institutions met in Italy to define the strategy to save approximately 6 million out of the 10.9 million children under the age five who die annually. The expert group concluded that at least one proven and practical intervention is available for preventing or treating each main cause of death. If all these interventions are made universally available (meaning, a 90 per cent coverage), about 63 per cent child deaths could be prevented.

This, in effect, means that the interventions needed to achieve the UN mandated Millennium Development Goal (MDG) of reducing child mortality by two-thirds by 2015 are available, but are not being delivered to the mothers and children who need them.

Breastfeeding � defined as exclusive breastfeeding for the first six months and continued breastfeeding for 6-12 months � was identified as the single most effective intervention that could prevent 13-15 per cent of all child deaths. This coupled with adequate complementary feeding could prevent 19 per cent of all child deaths.

Currently, only 35 per cent babies the world over are exclusively breastfed during the first four months. Malnutrition is highest in South Asia, where only about 45 per cent of 0-3 months babies are exclusively breastfed. In India, only about 20 per cent babies at six months are exclusively breastfed.

It is critical to understand that inappropriate feeding practices are intimately related to malnutrition, which fuels child deaths. Take the case of India, where 26 million children are born every year and about 60 million below the age five years are undernourished. In India, the Infant Mortality Rate (IMR) is 65 and Under-five Mortality Rate (U-5MR) is 95 per thousand born. Some 2.42 million children under the age five die each year; about 1.6 million children die during their first year itself. Most these deaths � caused by diarrhoea, pneumonia and neonatal infections � are preventable.

Promoting breastfeeding vs. checking HIV transmission

The major source of HIV infection in young children is mother-to-child transmission. The virus may be transmitted during pregnancy, labour and delivery, or through breastfeeding. Recent evidence suggests that 5�20 per cent of infants born to HIV-positive women get infected through breastfeeding.
Among women recently infected with HIV, the risk of transmission through breastfeeding is two times higher than for women infected before or during pregnancy, because of the high viral load shortly after initial infection. Other factors that significantly increase transmission rates include �mixed feeding� of infants (meaning, both breastfeeding and artificial feeding) and preventable breast conditions like sore nipples and mastitis.

In 2003, nine UN Agencies endorsed the HIV and Infant Feeding: Framework for Priority Action to guide nations about key actions pertaining to infant and young child feeding with regards to special circumstances like HIV. Its aim is to create and sustain an environment that encourages optimal feeding practices for all infants while scaling up interventions to reduce HIV transmission.
The Global Strategy for Infant and Young Child Feeding � developed jointly by UNICEF and the WHO, and approved by the World Health Assembly in May 2002 �provides a strong basis for policy and action on the issue of appropriate feeding practices for infants and young children. In balancing the need for reducing the risk of HIV transmission to infants with the necessity of minimizing the risk of other causes of morbidity and mortality, the UN guidelines state: �when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life.�

To help them make the best choice, the HIV-positive mothers should receive counseling and information about the risks and benefits of various infant feeding options based on local assessments, and guidance in selecting the option most suitable for their situation. They should also have access to follow-up care and support, including family planning and nutritional support.

Why recommend exclusive breastfeeding for all babies?

More than 99 per cent mothers in South Asia are HIV-negative. Of the remaining 1 per cent, only a minority gets tested for HIV. The unnecessary use of breast milk substitutes by mothers who are unaware of their HIV status or are HIV-negative needs to be avoided. Further, the risk of HIV transmission increases in case of �mixed feeding�.

In formulating a global strategy, UN�s HIV And Infant Feeding: Framework for Priority Action proposes certain key actions for consideration by governments. It puts the following as the first priority action: �Develop or revise (as the case may be) a comprehensive national policy on infant and young child feeding, which includes HIV and infant feeding.�

As such, all mothers should be encouraged and supported to breastfeed exclusively for six months. As a best practice, breastfeeding should continue alongside complementary feeding till 24 months. The importance of appropriate feeding practice is obvious as more than 90 per cent of the brain develops during this critical period.

Exclusive breastfeeding is best maintained when mother and baby have a skin to skin contact and breastfeeding starts within one hour of the baby�s birth; when a baby is properly attached to the breast (this prevents sore nipples and mastitis); and when baby practices demand feeding and suckles without any interference or pacifiers (this ensures effective and adequate milk supply). The support and counselling by skilled personnel can go a long way in ensuring this. Since these inputs require the skill development of grassroots workers, and are time intensive, they often remain ignored.

It would be a critical mistake if we fail to attend to such direct and cost saving actions to improve infant wellbeing and health. Benefits of such direct interventions during the first two years of life are proven, affordable and sustainable.

According to the Global Strategy for Infant and Young Child Feeding, �Inappropriate feeding practices and their consequences are major obstacle to sustainable socio-economic development and poverty reduction. Governments will be unsuccessful in the efforts to accelerate economic development in any significant long-term sense until optimal child growth and development, especially through appropriate feeding practices, is ensured.�

The strategy calls on the member states to act urgently. It urges all national policymakers, public health authorities, professional bodies, UN agencies, technical programme managers and NGOs to promote breastfeeding for the survival, growth and development of their children and societies.

Sources:
Ministry of Health, Government of India
UNICEF�s The State of the World�s Children reports

Dr. Arun Gupta is the National Coordinator, Breastfeeding Promotion Network of India (BPNI), and Regional Coordinator, International Baby Food Action Network (IBFAN) Asia Pacific.