Ten years ago India had joined many other countries in endorsing the goals set out at the World Summit for Children. These goals ensured a healthy future for its children by bringing down malnutrition.
data tells a grim story. Malnutrition among children is a major concern
as 47% under the age of three are underweight. These figures have change
only marginally during last six years when we compare the data from
NFHS- 21 with NFHS -12.
This paper examines the reasons and relationship of poor feeding practices and their link with malnutrition and offers possible solutions to reduce malnutrition. This paper also advocates intervention to improve infant feeding practices as an aide to reduce childhood malnutrition, besides addressing larger issues like poverty, health services, household food security and maternal nutrition, which of course influence the nutrition outcome of women and children.
Status of infant feeding practices in India
Although exclusive breastfeeding is advised till about six months of age, It has not shown a significant improvement over last six and half years as shown by NFHS-2 results. Figure 3 shows that 19.4% are exclusively breastfed at six months and 54.2 % at 3 months of age. It means half the babies born in India are subjected to faulty feeding practices within a short period of three months despite all the efforts made in this direction. Bottle-feeding rate also remains the same 14.5% below 12 months of age
1. Initiation of breastfeeding
Putting the baby to breast within half hour of birth is the first and the foremost step to optimal breastfeeding as at this time the baby's suckling reflex is strongest, and the baby is more alert.3,4. Early initiation stimulates breastmilk production through prolactin reflex and also stimulates oxytocin reflex for better milk flow from mother's breast to the baby. It helps to ensure colostrum, which provides the infant with the antibacterial and anti-viral protection, and the crucial nutrition needed at this hour. Early initiation of breastfeeding is associated with fewer breastfeeding problems and better mother-infant relationship5. Babies who are put to breast earlier have been shown to have higher core temperatures and less temperature instability6.
2. Exclusive breastfeeding
Infants who are exclusively breastfed for first six months do not require any other food or drink. In fact giving any thing including non-nutritive fluids would replace breastmilk.7 Exclusively breastfed babies have significantly less gastrointestinal and respiratory illness including ear infections and asthma, than those who are not breastfed8. Exclusive breastfeeding while reduces the risk of diarrhea also contributes to positive impact on nutrition status of child while recovering from diarrhea9. In addition, the breastfeeding mother has a reduced incidence of post-partum bleeding and thus anemia, reduced risk of breast and ovarian cancer, reduced risk of osteoporosis, and other beneficial effects such as increased child spacing due to delayed resumption of ovulation.10
3. Timely and appropriate complementary feeding
After six months, infant's requirements cannot be met with breastmilk alone. This is the time to begin complementary foods, which are of good quality and in adequate amounts. This is necessary to prevent malnutrition including anemia. During this period additional foods and fluids are provided to the baby along with breastmilk. A study 11 has shown that early introduction of complementary food does not result in improved growth velocities or food acceptance. Several other studies have also documented that early start of complementary foods earlier than 6 months, replaces breastmilk intake and does not increase caloric intake and none of these studies reported any benefit of starting these foods earlier than six months12. Replacing breastmilk means losing fats, energy and other micronutrients. It would therefore be important to maintain high levels of breastfeeding along with introduction of complementary foods, which are high nutrition density.
Malnutrition cycle, when it strikes
Malnutrition in children is a major concern in India as about 47% of
children under three years are underweight, which number to about 60
At 6-11 months of age malnutrition to 43%, which could be due to inadequate breastfeeding and inappropriate not exclusive breastfeeding and inappropriate complementary foods and then at two years this percentage goes unto about 63% again could be due to inadequate food or inappropriate practices.
Not much has changed in six and a half years when we compare malnutrition data between NFHS -2 and NFHS -1, it is seen that percentage of children underweight is still extremely high. (Fig 2)
Malnourished children have delayed milestones and impaired cognitive development, and are likely to be handicapped for life if an innovative approach is not adopted. Thus, malnutrition impairs intelligence, strength, energy and productivity. A recent study by the Government of India has established that the annual loss of productivity on account of malnutrition is of the order of more than Rs. 33,000 Crores.
The commitment to improve infant feeding
There have been several national and international policy commitments where support to infant feeding has been promised. Having known the current situation, let's see what is the State's commitment.
Let us examine some key policy documents
The IMS Act
Here is a quote from the Statement of Objects and Reasons, which was placed before the Parliament, while presenting the Bill, the "Infant Milk Substitutes, Infant Foods and Feeding Bottles (Regulation of Production, Supply and Distribution) Act, 1992".
"…………..Inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in our children…" "…In the absence of strong interventions designed to protect, promote and support breastfeeding, this decline can assume dangerous proportions subjecting millions of infants to greater risks of infections, malnutrition and death……..…"
Table-2 (Annex 1) very briefly presents the national and international events or documents that identify the need for an increased focus on the newborn, infant and young child nutrition through improved/enhanced support to infant and young child feeding and provide sufficient technical and political support for infant feeding.
The National programs
The Integrated Child Development Services (ICDS), the largest programme on nutrition to reach children has taken up a mission to reduce malnutrition under two years by promoting the practice of exclusive breastfeeding from birth to six moths and timely and active complementary feeding (with continued breastfeeding up to two years.
Plan for Action for the child enumerates certain activities to reduce
malnutrition and Infant Mortality Rate (IMR) includes following activities,
The RCH program guidelines focus on infant feeding and recognize that timely and adequate breastfeeding is the best guaranteed aid of ensuring that the newborn is not malnourished; it also ensures that infant is not exposed to avoidable infections and breastfeeding has a major role to play in strategies for improving child survival.
national events support infant feeding
feeding practices: the key determinant of malnutrition
Infant feeding practices that have a link with malnutrition and how these contribute to malnutrition is described in this section. Bottle-fed babies are more prone to infections not only because of unclean bottles but also because of a loss of potential immunity transferred from the mother through breastmilk.
The age window when growth stunting occurs coincides with two important time periods9: the first is the time when inadequate breastfeeding is given and when fluids other than breastmilk are introduced into babys diet and second when complementary feeding is initiated. Faulty feeding practices begin with giving any other fluids or milk but breastmilk before six months of life. Such practices have immediate and long-term consequences on the health, growth and development of a child. Studies have showed the link between bottle-feeding and increased disease burden and deaths as well.13
Additional disadvantage to provide artificial feeding to a baby is socioeconomic as a family has to spend approximately Rs.1100 per month on milk and related products to feed a baby during the first six months.14 the economic impact is enormous as money spent on milk and related products could be utilized to buy food for the mother and the child.
How poor feeding practice contribute to loss of essential nutrition is described below.
Giving babies other fluid and milks before breastfeeding is initiated
This practice is known as giving pre-lacteal feeds, this is a poor practice that contributes to increased infections in newborn period and delays the establishment of breastfeeding. Babies lack desire to suckle after being fed with something else leading to decrease in mothers milk production, which is dependant on suckling of the baby. Availability of breastmilk to the newborn babies decreases. Such a practice contributes to loss of essential nutrition and places babies at risk of illness and even death.
Late initiation of breastfeeding
If breastfeeding is started late, it will interfere in successful establishment of exclusive breastfeeding and leads to early cessation of breastfeeding. This faulty practice contributes to decline in breastfeeding, deprives the baby of essential nutrition, care, stimulation and affection.
artificial feeding before six months
Table 1 shows the link between artificial feeding and increased disease risks. This faulty feeding practice thus affects both the dietary intake and health condition, which are the immediate determinants of nutritional and developmental status of a child. Starting bottle-feeding/artificial feeding as early as first month also makes the baby to refuse breastfeeding.
and late start of complementary foods
Early introduction of complementary foods before the age of six months leads to displacement of breastmilk and also increases risk of infections like diarrhea, which further contributes to weight loss and malnutrition. Besides this, babies are also not ready to receive the complementary foods due to immaturity of the gastrointestinal, neuro- developmental systems and the kidneys.
· Late introduction of complementary food leads to insufficient calorie intake leading to inadequate weight gain, as breastmilk alone is not sufficient to provide the needed nutrition. Nutritionally inadequate or contaminated food also is one of the major causes of malnutrition in infants and young children.
Reasons of faulty feeding practices
The reasons for faulty feeding practices are many. The reasons include:
1. Aggressive promotion of commercial infant milk substitutes/formulas and infant foods by the manufacturers
Manufacturers of infant foods and infant milk substitutes and feeding bottles take to all possible tactics in the promotion and marketing their products. They put profits before health. This undermines the success of breastfeeding especially when health workers are unsupportive and not well informed.
There is perceptible linkage between the advocacy of infant formula and bottle-feeding and incentive-loaded publicity by infant food manufacturing companies.
2. Lack of adequate and accurate information and social support
Erosion of value of breastfeeding in the society and lack of understanding of the needs of women has led to inadequate support to breastfeeding mothers. Inappropriate practices are also due to lack of accurate and unbiased information compounded by inadequate awareness among people regarding optimum infant feeding practices
3. Lack of skilled support from the health workers in hospitals and nutrition workers at grass root level
Most health and nutrition workers in hospitals especially those working in pediatric and maternity areas, and at the periphery dont have adequate knowledge and skills to help women in establishing and maintenance of exclusive breastfeeding. And because of this, they overlook the importance of counselling on optimum infant feeding practices.
Current Initiatives to improve infant feeding practices
What are various initiatives in this direction are
1.1. Protecting infant health through enactment of the IMS Act
India was the 10th country in the world to translate the International Code of Marketing of Breastmilk Substitutes into the legislation in 1992. The Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992(IMS Act) was enacted in 1992 and came into force in 1993. This has become an important tool in protection of breastfeeding from the commercial influence that undermines breastfeeding.
The IMS Act protects the basic right of mother and child to adequate health and nutrition. The Act seeks to regulate their production, supply and distribution.
1.2. Enactment of Cable Television Network (Amendment) Act and the Rules, 2000
The Information and Broadcasting Ministry has banned direct or indirect promotion of infant milk substitutes, feeding bottles and infant foods through amendment to the Act in September 2000.
1.3. Baby Friendly Hospital Initiative (BFHI)
This is one of the major initiatives that provide guidelines to the hospitals to establish Ten steps to successful breastfeeding. The program has been found to be effective in changing hospital practices to support breastfeeding women.
1.4. The Integrated Child Development Services (ICDS)
Department of Women and Child Development has been managing this comprehensive program in the area of nutrition of the mother and the child with very clear objectives but lot more needs to be achieved. Element to promote exclusive breastfeeding and complementary feeding needs increased emphasis and staff needs skills training.
1.5. The RCH programme
Ministry of Health ad Family Welfare (MOHFW) has been running a major programme for the benefit of health sector in maternal and child health. The Reproductive and Child Health (RCH), needs to enhance emphasis on promoting appropriate infant and young child feeding.
1.6. NGO Initiatives
Many NGOs including Association for Consumers action on Safety and Health (ACASH) and Breastfeeding Promotion Network of India (BPNI) have been active in protection, promotion and support of breastfeeding in India. These NGOs are devoting time and efforts towards improving these practices in the hospitals and also to protect breastfeeding from the industrys promotional practices. Considerable progress has been made in the past ten years in changing policies and practices on infant feeding.
1.7. Professional bodies
Almost all professional bodies like Indian Medical Association (IMA), Indian Academy of Pediatrics (IAP), Federation of Obstetrics & Gynecological Societies of India (FOGSI), National Neonatology Forum (NNF) and Trained Nurses Association of India (TNAI) have contributed to protection, promotion and support to optimum infant feeding programmes in one way or the other.
Despite the efforts listed above and the commitments, half the babies under the age of three months are exclusively breastfed only while others adopt artificial feeding/bottle-feeding. And only a third of infants between six to nine months are given timely complementary feeding. This situation contributes to malnutrition, illness and deaths and definitely warrants a change.
It is well recognized that breastfeeding though an essential element in several programs including ICDS and RCH is relegated to background being a soft subject and malnutrition has not shown appreciable decline.
Gaps that need to be addressed:
2.1. Lack of proper emphasis in national programs
There is an identified need to increase focus on infant feeding support in the national programs
2.2. IMS Act lacks teeth
The manufacturers of infant milk substitutes, infant foods or feeding bottles have violated the IMS Act fairly regularly.
2.3. Inadequate skilled health care support
Studies have shown if women are helped and receive skilled support during pregnancy and at the time of childbirth, it increases the chances and duration of exclusive breastfeeding. The gap is lack of adequate skills with health and community workers at all levels.
2.4. Incomplete information in text books
The breastfeeding and infant feeding component of textbooks of pediatrics and obstetrics on need revision in view of the incomplete information available at the moment.
2.5. Lack of adequate and accurate information
This is a big gap; campaign to provide accurate and unbiased information to all cannot be overemphasized.
2.6. Inadequate support to women at work
Most women work in informal /unorganized sectors and there is not enough support in the community or at work place to successfully breastfeed their babies especially during first year. Even in the organized sector sufficient maternity leave is not provided to facilitate exclusive breastfeeding for first six months except in Punjab and Haryana.
2.7. Inadequate support to women in the community.
Women lack adequate support within her home, family and the community. As community devalues breastfeeding and community workers not adequately trained to counsel women on appropriate infant feeding, women make uninformed decisions, which interfere with nutrition of their children.
BPNI offers following solutions to improve infant feeding practices.
There are two major areas for actions for governments, NGOs and others concerned, 1.General and 2. Specific
3.1.1. Enhancing policy attention to infant feeding
Bringing the issue of malnutrition and infant feeding practices for a debate at the level of the cabinet, the Parliament, policy meetings of concerned departments, and standing committees of the Parliament would be of great help.
3.1.2. Resource allocation
A well-defined resource allocation including finance and strategic planning is needed to promote exclusive breastfeeding and timely complementary feeding as the single most cost-effective child survival strategy.
3.2.1. Strengthening of the IMS Act through amendment.
As there have been several violations of the law in the past few years, the most important being the violations under section 3 and 7 pertaining to the advertisements of infant foods. There are certain identified areas that need strengthening in the IMS Act. These are
Section 3: about promotion: The infant foods need to be included in the section 3 (a) to stop all kind of advertisements for promotion of infant foods.
Section 9: regarding health care system needs to be strengthened to stop any sponsorship or inducements whatsoever to health care institutions/persons.
Section 10: This section needs amendment to include all manufacturers and concerned companies rather than their employees within the ambit of prohibition of production or distribution of education materials for pregnant women.
3.2.2. Strict enforcement of the IMS Act
Systematic monitoring of the IMS Act also would provide useful information to strengthen the legislation further. Training of concerned staff is necessary and will help strict enforcement of the law and check the violations.
3.2.3. Training of health care staff in hospitals.
Supporting and ensuring training of all health and community workers in skills in management of lactation and counselling for appropriate complementary feeding would benefit all mothers and babies. BFHI programme should continue to be in center stage and training input should be ensured as a pre requisite to achieve long-term effects.
3.2.4. Training of staff in ICDS and RCH
Supporting and ensuring appropriate training of all community workers in skills in counseling for appropriate breastfeeding and complementary feeding practices would benefit all mothers and babies.
3.2.5. Strengthening education curriculum
Supporting and ensuring modification of curriculum as a long term strategy especially in medical and nursing schools, training institutes of ANMs and anganwadi workers to include lactation and breastfeeding management education. Curriculum of school children should also be strengthened to inculcate positive attitude towards childcare and nutrition.
3.2.6. Information support
To benefit all sections of the society it is essential to support and ensure a well-designed campaign to provide accurate and unbiased information with specific messages on initiation, maintenance of exclusive breastfeeding and appropriate complementary feeding. Locally and culturally appropriate material should be developed and targeted to young children, adolescents, fathers and older members of the community.
3.2.7. Support at workplace
Advocating and ensuring maternity benefits to working women especially in the unorganized sector should also make this support much wider and will greatly help to women.
3.2.8. Womens nutrition
Community support programmes that focus on life cycle approach and focus on improving womens nutrition should continue to make a long-term strategy.
About 33% children born are underweight, and malnutrition affects about half the children under three, and it sets in the most during second half of infancy. Exclusive breastfeeding during the first six months and continued breastfeeding for two years and beyond along with introduction of appropriate complementary foods at six months could contribute significantly in reducing childhood malnutrition. Faulty feeding practices like pre-lacteal feeds, exclusive breastfeeding, bottle- feeding, inappropriate complementary feeding place infants and young children at risk of illness, malnutrition and even death.
To enhance the infant feeding practices, Government of India and several interested parties have made significant efforts in this direction but it is felt that this is not enough.
Despite the commitments at national and international level, nutrition of infants and young children and the women continue to be very poor in the country. What is needed is the transformation of this heightened consciousness into effective action that ensure breastfeeding rights of women and children.
Certain gaps have been identified at several forums. Infant feeding needs increased support.
The age groups that are affected the most by malnutrition are young infants when they are introduced supplements of fluids other than breastmilk and complementary foods. Thus, targeting interventions to this age group may be more cost-effective than programmes that include a wider age range.
Interventions to improve feeding practices should receive our attention now than later. Besides addressing larger issues like poverty, health services, household food security and maternal nutrition, this would be the most practical solution to aide in reducing malnutrition among young children.
Can we move forward? Yes!
1. National Family Health Survey -2, 1998-99 Institute of Population Sciences, Mumbai, Govt. of India MOHFW.
8. Popkin BM, Adair L, Akin JS, et al. Breast-feeding and diarrheal morbidity. Pediatrics 1990; 86(6): 874-82.
9. Brown K, Dewey KG, Allen H. WHO 1998. Complementary Feeding of Young Children in Developing Countries, a review of current scientific knowledge. Geneva, World Health Organization, 1998
10. Labbok M, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look, P. Multicenter study of the lactational amenorrhea method (LAM): Efficacy, duration, and implications for clinical application. Contraception, 1997; 55:327-36.
11. Cohen RJ, Landa Rivera L, Canahuati J, et al. Delaying the introduction of complementary food until six months does not affect appetite or mother's report of food acceptance of breastfed infants from 6-12 months in a low income Honduran population. Journal of Nutrition 1995; 125: 2787-92.
12. Armstrong H. Breastfeed first or give soft foods first? A review of current recommendations. A discussion paper prepared for UNICEF. New York: UNICEF, July 1993.
13. Victora CG, Smith PG, Vaughan JP et al. Evidence for protection by breastfeeding against infant death from infectious diseases in Brazil. Lancet 1987; 319-322.14. Gupta A, Kuldeep K. Economic Value of Breastfeeding. The National Medical Journal of India 1999; 12(3):123-127.
We gratefully acknowledge the contribution and support of Mr. R.V. Pillai, Mr. G.S. Bhargava who helped us in preparing this document in the present form.
We are especially thankful to Pat, Rita, Deepika, Nirmala, Nobel and GP Mathur for providing useful comments on the initial drafts.
Jessy, Amit and Yogender deserve special appreciation for their untiring efforts to make this publication possible in the present form.