Long Duration Breastfeeding

Natural, Healthy—and in EmergenciesLife Saving

One Asia Breastfeeding Partners ForumColombo, Sri Lanka

November 18-21, 2009

Keynote Address Presented by:Professor Michael Latham

Cornell UniversityIthaca, NY 14850, USA

The Crisis of Malnutrition Among Underprivileged Families A hidden crisis contributing to half of all

young child deaths

A crisis that can only be solved by assuring children everywhere, with adequate food, health, and care

Food, health, and care – Breastfeeding contributes to all three

2008 Lancet Series on

Maternal and Child Undernutrition Concluded:

Undernutrition (stunting, wasting, and intrauterine growth retardation) are responsible for:

2.2 MILLION DEATHS PER YEAR

Sub-optimum breastfeeding responsible for:

1.4 MILLION OF THESE DEATHS PER YEAR IN CHILDREN UNDER 5 YEARS OF AGE

WHO/UNICEF: Global Strategy for Infant and Young Feeding (2003)

“As a global public health recommendation, infants should be exclusively breastfed for

the first 6 months of life…”

Thereafter, “…infants should receive nutritionally adequate and safe

complementary foods while breastfeeding for up to 2 years of age or beyond.”

WHO/UNICEF: Global Strategy for Infant and Young Child Feeding (2003)

Breastfeeding is an unparalleled way of providing ideal food for the healthy growth

and development of infants; it is also an integral part of the reproductive process with important implications for the health

of mothers

INEQUITY…

…in incomes, education, healthcare, etc is

THE MAJOR CAUSE OF HUNGER AND MALNUTRTION

The rich get richer (nations and people)The poor get poorer (in the North and South)

Conceptual Framework of Causes of Malnutrition

Inadequateaccess to food

Inadequate care forchildren and women

Insufficient health services & unhealthy

environment

InadequateDietary Intake

Disease

Malnutrition

Resources and ControlHuman, economic and

organizational resources

BasicCauses

UnderlyingCauses

ImmediateCauses

Manifestation

Inadequate Education

UnderweightModerate and Severe

(WHO)

WastedModerate and Severe

(NCHS/WHO)

South Asia41% 18%

Sub-Saharan Africa24% 9%

Nutritional Status of Children (0-59 months) in South Asia and Sub-Saharan Africa (UNICEF

2009)

Percentage of Children 0-59 Months Underweight and Stunted1

Moderate and Severe Underweight (WHO)

Severe Underweight Moderate and Severe Stunting (WHO/NHCS)

Afghanistan 39 12 54

Bangladesh 46 - 36

India 46 - 38

Indonesia 28 9 -

Malaysia 8 1 -

Myanmar 32 7 94

Nepal 45 10 43

Pakistan 38 13 37

Sri Lanka 29 - 14

Thailand 9 0 12

Vietnam 20 5 36

1. UNICEF. The State of the World’s Children. 2009.

Percentage of Children 0-59 Months with Moderate or Severe

WastingModerate and Severe

Wasting (NCHS/WHO)

Afghanistan 7

Bangladesh 16

India 19

Indonesia -

Malaysia -

Myanmar 9

Nepal 12

Pakistan 13

Sri Lanka 14

Thailand 4

Vietnam 8

Infant Mortality Rate (under 12 months) and Under 5 Mortality Rate

Infant Mortality Rate Under 5 Mortality Rate

1990 2007 1990 2007

Afghanistan 168 165 260 257

Bangladesh 105 47 151 61

India 83 54 117 72

Indonesia 60 25 91 31

Malaysia 16 10 22 11

Myanmar 91 74 130 103

Nepal 99 43 142 55

Pakistan 102 73 132 90

Sri Lanka 26 17 32 21

Thailand 26 6 31 7

Vietnam 40 13 56 15

Infant Mortality Rate (under 12 months) and Under 5 Mortality Rate

Infant Mortality Rate

Under 5 Mortality Rate

1990 2007 1990 2007

Bangladesh 105 47 151 61

India 83 54 117 72

Nepal 99 43 142 55

Pakistan 102 73 132 90

Sri Lanka 26 17 32 21

Percentage of Children Under 6 Months of Age Exclusively Breastfed, and Still Breastfed at 20-23

Months Exclusively Breastfed

(<6 months)Still Breastfeeding

(20-23 months)

Afghanistan - 54

Bangladesh 37 89

India 46 77

Indonesia 40 59

Malaysia 29 12

Myanmar 15 67

Nepal 53 95

Pakistan 37 55

Sri Lanka 53 73

Thailand 5 19

Vietnam 17 23

Deaths Attributable to Underweight

• 816,000 diarrhea deaths

• 1,043,000 pneumonia deaths

• 261,000 measles deaths

• 549,000 malaria deaths

• 154,000 PEM deaths (direct)

• 127,000deaths from perinatal conditions

• 3,727,000 deaths overall = 54% all child deaths

Distribution of 11.6 million deaths among children less than 5 years old in all developing countries

Anemia prevalence by global region, sex and age

0

10

20

30

40

50

60

70

Africa

Amer

icas*

E. Medit

E. Euro

pe

South A

sia

SE Asia

U.S.A

.

0-4 y

Women

*excludes North America

US Institute of Medicine Recommendation

Human milk is a sufficient source of iron for the first 6 months of life, but foods with bioavailable iron, iron-fortified foods or a low-dose iron supplement should be provided at 6 months or earlier, if supplementary foods are introduced before that time.

Immune Benefits of Breastmilk

Impact on Diarrheal InfectionsPrevalence of diarrhea in infants under 2 mo in Peru in 1988 according to feeding pattern

Source: Victora C (1996)

Impact on Respiratory InfectionsRisk of pneumonia in children under two years of age in two Brazilian site in 1993-5 according to type of milk

Source: Victora C (1996)

Infant mortality associated with NOT breastfeeding (pooled data from Brazil, Pakistan, Philippines)

0

1

2

3

4

5

6

7

0-1 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo

Age

Od

ds

Rat

io

From: WHO Collaborative Team on the Role of Breastfeeding on the Prevention of Infant Mortality (2000)

Feeding 6-24+ Month Old Children

Opportunity for the breastfeeding community

Exclusive Breastfeeding for 6 Months It took 45 years of our involvement and

actions to finally get: WHO, UNICEF, pediatric societies and

governments of many countries to accept and advise: Exclusive Breastfeeding for 6 Months

In 2009, many countries, including those with a breastfeeding culture, only a minority of mothers exclusively breastfeed for 6 months.

But some real successes in increasing percentage of exclusive breastfeeding have been reported.

WABA, IBFAN, La Leche League, ILCA and other breastfeeding allies, UNICEF, WHO, and countries:

Still have much work to do to greatly expand:

Percent of newborns put to breast immediately after birth

Percent exclusively breastfeeding for 6 months

Improving

Breastfeeding Children 6-24+ Months of Age 1. Duration

Actions to increase the length of breastfeeding

2. Volume of Breastmilk Encouraging mothers at 6 months to introduce

other foods while maintaining high volumes of breastmilk to 24 months and beyond

3. Advise Mothers At each feeding, before offering

complementary foods, always breastfeed first

Advantages of Long Duration, High Volume Breastfeeding Nutritional Birth spacing Economic Health (reduced infections) Psychological (caring) Agricultural Environmental Reduced breast, and other, cancers in the

mother Other

Breastfeeding for 6 – 24+ Month Old Children There appear to be:

No indicators

No programs for maintaining or improving it

No guidance or guidelines

No social or political declarations on importance, nor on what to do about it

Complementary Feeding for Children Breastfed from 6-24+ Months When continuing high volumes of

breastmilk… There is less need for high protein

commercially manufactured complementary foods

More likely that available family foods together with breastmilk will satisfy nutritional needs of baby

Actions to Improve Breastfeeding for 6-24+ Month Old Children Protection

Code enforcement; prevention of actions that influence mothers to reduce duration, frequency, and volumes of breastmilk

Support Actions that assist mothers to breastfeed more and

longer; actions to make it easier for women who work away from home to continue breastfeeding; assist mothers with breastfeeding problems; etc

Promotion Education of community healthworkers, nurses, doctors,

and others; education of mothers, fathers, and families; government support and promotion

Research Needed Lack of much good data on importance of

breastfeeding 6-24+ children 1. What common volumes of breastmilk are

provided at different ages in different groups?

2. What factors seem to positively influence higher volumes and longer duration?

3. What are negative influences? Time; women’s work, commercial influences, etc

The Contribution of Breastmilk to Nutrient Requirement of Child 6-24 Months of Age Acceptance by UNICEF, WHO, Pediatric

Societies, etc., that 6 months of breastfeeding can provide 100% of nutrients for the infant

Assumption #1 Healthy, normal, well-nourished 6 month old

would be receiving 700-1000mL of breastmilk per day

Assumption #2 Healthy mothers are usually capable of

providing 500-850mL of breastmilk daily after their infant is 6 months of age

ENERGY REQUIREMENTS FOR CHILD FROM 1-24 MONTHS OF AGE AND ENERGY CONTENT OF DIFFERENT DAILY AMOUNTS OF BREASTMILK

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

800.0

900.0

1000.0

0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 23-24

Age (months)

Ener

gy (k

cal/d

ay)

1000mL

850mL

750mL

500mL

PROTEIN REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND PROTEIN CONTENT OF DIFFERENT DAILY AMOUNTS OF BREASTMILK

0

2

4

6

8

10

12

14

16

18

20

0-6 7-12 13-24

Age (months)

Prot

ein (g

/day)

1000 mL

850 mL

750 mL

500 mL

VITAMIN A REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND VITAMIN A CONTENT IN BREASTMILK

0

100

200

300

400

500

600

700

800

0-6 7-12 13-24

Age (months)

Vita

min

A (m

cg/d

ay)

1000 mL

850 mL

750 mL

500 mL

VITAMIN C REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND VITAMIN C CONTENT IN BREASTMILK

0

10

20

30

40

50

60

0-6 7-12 13-24

Age (months)

Vitam

in C

(mg/

day)

1000 mL

850 mL

750 mL

500 mL

CALCIUM REQUIREMENTS FOR CHILD 0-24 MONTHS OF AGEAND CALCIUM CONTENT IN BREASTMILK

0

100

200

300

400

500

600

0-6 7-12 13-24

Age (months)

Calci

um (m

g/da

y)

1000 mL

850 mL

750 mL

500 mL

Percent of Nutrient Components of 750mL of Breastmilk

Age in Months0 – 6 7 – 12 13 – 24

Energy 100% 70.6% 57.9%

Protein 148% 123% 104%

Vitamin A 141% 113% 188%

Vitamin C 75.0% 60.0% 200%

Calcium 107% 83.3% 45.0%

Variability in Nutrient Contribution Based on Nutritional Status of Mother 1. Only rather serious malnutrition for the

lactating woman results in her inability to produce reasonable quantities of breastmilk

2. Deficiencies in Vitamin A, Vitamin D, and Thiamine in diet of mother, substantially influences levels of these nutrients in breastmilk (much less so with other nutrients)

Thiamine Deficiency

“Clinical infantile beriberi due to thiamine deficiency in mother is the only serious deficiency that regularly occurs in infants under 6 months of age receiving adequate quantities of

breastmilk (now extremely rare).”

Breastmilk Potential Contributions to Nutritional Requirements of 6-24 Month Old Infants

Surprisingly there is not a great deal of information about amounts of breastmilk fed beyond 6 months in different societies and circumstances

Clearly 850mL of breastmilk would contribute very substantially to % of energy, protein, and micronutrient requirements from age 6-24 months

But also 200-500ml would still contribute useful amounts of nutrients

US Institute of Medicine, National Academy of Sciences 1991 Statement Women are able to:

“Produce milk of sufficient quantity and quality to support growth and promote the health of infants even when the mother’s supply of nutrients is limited.”

Infant Feeding In Emergencies Breastfeeding plays a vital role in

emergency response worldwide

THEREFORE

Important to advocate for active protection and support of breastfeeding before and during emergencies

Infant Feeding In Emergencies If a tsunami swept all food off an island:

Who would be the first to die? Who would survive the longest?

Elderly Sick Pregnant women Other adults Older children Formula fed infants Breastfed infants

Infant Feeding In Emergencies Those who would die first:

FORMULA-FED INFANTS

Those who would survive longest:

BREASTFED INFANTS

Myths about Breastfeeding

Not true that:

Malnourished mothers cannot breastfeed

Stress prevents lactation

HIV-positive mothers should never breastfeed

Relactation impossibly difficult

Free or Subsidized Supplies in Emergencies In general

Donated (free) or subsidized supplies of:

Breastmilk subsitutes (infant formula) Bottles and teats

should in most instances be avoided in emergency situations

Examples of Emergencies

Floods in Botswana in 2006

96% of infants hospitalized for diarrhea were formula-fed

21% died

Examples of Emergencies

Indonesian (Yogyakarta) Earthquake in 2006

25% receiving formula had diarrhea

12% not receiving formula had diarrhea

Ready to Use Therapeutic Foods

(RUTFs)

Possibly a new threat to improved breastfeeding for

children 6-24+ months of age

Definition of RUTFs (WHO, WFP, UNICEF)

“Ready to Use Therapeutic Foods (RUTFs) are high energy fortified, ready to eat foods, suitable for the treatment of children with severe acute malnutrition. These foods should be soft or crushable, and should be easy for young children to eat without preparation. At least half of the proteins contained in the foods should come from milk products.”

3 Largest Users of RUTFs Worldwide UNICEF

MSF (Medecins sans Frontieres or Doctors without Borders)

Clinton Foundation (Mainly with U.S. PEPFAR funds for HIV/AIDS)

Note: An appropriate use for RUTF might be very young AIDS orphans

Emerging Vocabulary

Ready-to-Use Food (RUF) fortified foods that do not require preparation, dilution or

refrigeration

Lipid-based nutrient supplements (LNS) RUF with majority of the energy provided by lipids

Ready-to-Use Therapeutic Food (RUTF) Plumpy’nut and local variations formulated to replace F-100

rehabilitation milk

Ready to Use Supplementary Food (RUSF) Nutributter , Plumpy’doz and local variations providing

supplemental energy + micronutrients

Community-based Therapeutic Care (CTC) Community-Management of Acute Malnutrition (CMAM)

outpatient / home-based nutritional rehabilitationSource: www.ilins.org

The Bigger Policy Players Nutriset France

UN agencies (UNICEF, WFP, WHO)

Valid International / Valid Nutrition / Concern Worldwide

Medicins Sans Frontiers / Access to Essential Medicines

USAID FANTA Supply Chain Management Services (PEPFAR-related procurement)

Clinton Foundation Support development of national treatment guidelines expanded access to RUTF by purchasing supplies (33 countries by 2010) Promote market competition / encourage local production

MSF – Niger Research 2006 - Cluster randomized study of 12

villages during famine season (JAMA 2009)

6 villages - 3-month distribution of 500 kcal/d RUTF (F-100) to all children age 6-59 mo with WAZ > 80% NCHS

6 villages no supplement

After 8 months 36% reduction wasting; 58% reduction severe wasting

No mortality effect

RUTFs largely developed and promoted by Medecins Sans Frontieres (Doctors Without Borders)

A much admired organization providing doctors and healthcare in incredibly difficult areas and situations

Received well deserved Nobel Peace Prize in 1999

Medecins sans Frontieres (MSF)

RUTFs effective way to treat Severe Acute Malnutrition (SAM) Including Kwashiorkor and Nutritional

Marasmus

Now being commercially made as “Plumpy’Nut” and other brands Often contains peanuts, milk powder, etc.

Treatment of SAM Before RUTFsOur old (1960-?) treatment of severe protein energy

malnutrition (PEM) including Kwashiorkor and Nutritional Marasmus (now called SAM):

SCOM Mixture of Sugar, Casein, Oil, Milk (dry skim)

Advantages: Simple and available products Cheap In anorexic seriously ill child refusing food- easy to

give by intragastric tube Disadvantages:

Time to mix and variation greater than with RUTFs Also needed micronutrient supplementation

RUTFs now being promoted also to prevent malnutrition in 6-24 month old children not just for therapy to cure SAM.

A huge leap to use RUTFs for prevention Is this medicalizing and commercializing young

child feeding??

A “medicine” replacing family foods and sometimes threatening breastfeeding

RUTFs for Prevention Not Treatment

Concerns About Use of RUTFs for Prevention May undermine good breastfeeding in 6-

24+ month old children – already fragile

High costs of RUTFs relative to incomes of underprivileged families May violate WHO code or spirit of code

Program costs for RUTFs will reduce funding for other actions to reduce malnutrition and child deaths including promotion of breastfeeding

Approximate Cost of Plumpy Nut (or other RUTF) 1 day for 1 child = Vitamin A or deworming to

last 6 months

1 week for 1 child = Immunization against measles that protects for years

1 month for 1 child = Bednets for 3 children to protect against malaria

1 year for 10 children = Cost of small rural clinic or keeping 10 girls in school for 1 year

Recommendations UNICEF, WHO, FAO, WFP, and other

organizations including breastfeeding groups should meet to develop: Examples of guidelines for appropriate use of

RUTFs for prevention of malnutrition 1. Lactating women given RUTFs should always

breastfeed before offering RUTF 2. Make certain marketing and promotion of RUTFs

adheres to letter, and spirit, of WHO Code 3. Do no harm to

Breastfeeding Family feeding Local agriculture, etc

MSF and Other Proponents of RUTFs Should Have as a First Priority:

Make certain that almost all hospitals, health clinics, and other community centers that treat childhood malnutrition have regular and adequate supplies of RUTFs

Why is this not the first priority of MSF et al?

Consideration: Feed RUTFs to Mothers My suggestion:

When a lactating mother is given plumpy nut or other RUTF sufficient for total nutritional needs of 6-24 month old child

% of RUTF Fed:

Recommend: For Child For Mother

At 6 – 12 months 25% 75%At 12 – 18 months 50% 50%

At 18 – 24 months 75% 25%

This would help ensure good nutritional status of mother and child, and improve nutrient levels in breastmilk

Agreements No disagreement about crisis of childhood

malnutrition No disagreement about 0 – 6 months exclusive

breastfeeding No disagreement that from 6 months on other

foods need to be introduced The debate: How much effort, funding, actions

should be devoted to… Family foods RUTFs (commercial complementary foods) Longer and more breastfeeding for 6-24+ month old

children

Conclusions Longer duration of breastfeeding and greater

volume of breastmilk for children 6 – 24+ months of age is important for improved nutrition, health, etc. It is relatively neglected.

Commercial complementary foods, including RUTFs, are a feature of economic globalization and can constitute a threat to breastfeeding.

Greater actions are needed to protect, support, and promote more breastfeeding for children 6 – 24+ months of age.

Thank you for listening!