Transcript The very important contribution of breast milk to energy and other

The very important
contribution of breast milk to
energy and other nutrient
requirements beyond 6
months of exclusive
breastfeeding
SCN working group on
breastfeeding &
complementary feeding
Ellen Piwoz
Academy for Educational
Development
March 14, 2006
Recently, a great deal of attention has deservedly been given
to the need for appropriate and adequate complementary
feeding after 6 months
GUIDING PRINCIPLES FOR
COMPLEMENTARY FEEDING OF
THE BREASTFED CHILD (PAHO)
2002
2003
2005
However, sometimes this has caused us to lose sight of the
very important contribution of breast milk to child health and
survival AFTER 6 months
Contribution of breast milk energy intake to TOTAL ENERGY
REQUIREMENTS (+2 SD) of children 6-23 mo
6-8 mo
9-11 mo
12-23 mo
54%
44%
31%
(average)
(average)
(average)
28-79%
18-70%
8-54%
(range)
(range)
(range)
Dewey KG & Brown KH (2003) Food Nutr Bull 24: 5-28
Breast milk is a major source of other nutrients in
the diets of infants > 6 months – particularly in
developing country settings
% Contribution of BM to total intake of nutrients by Bangladeshi
6-8 mo
9-11 mo
Adapted from Kimmons et al, 2005, J Nutr 135: 444-451
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Ir
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B6
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Ri
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Fo
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100
80
60
40
20
0
Pr
ot
% contribution of BM
infants
Continued breastfeeding also provides other
benefits to families and infants
• Continued transfer of
many anti-infective
agents/immune protective
agents (sIgA, lactoferrin, lysozyme,
Median durations of breastfeeding, postpartum amenorrhea and abstinence in
selected African countries
(DHS stat-compiler)
Amenorrhea
ut
So
Abstinence
35
• Birth spacing
30
25
months
• Means for comforting
infants
Breastfeeding
a
Rw
IFN g, oligosaccharides, cytokines, etc.)
20
15
10
5
0
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an
nz
e
8
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9
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9
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Af
0
'0
3
'0
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ab
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Zi
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ny
Ke
• Protection against severe
illness & death
There is an increased risk of death if not breastfed
> 6 months, particularly amongst infants of mothers
who are more disadvantaged (WHO, Lancet, 2000)
OVERALL
OR
(95% CI)
0-1 mo
2-3 mo
4-5 mo
6-8 mo
9-11 mo
4.2
(2.8-6.3)
3.6
(2.4-5.5)
2.5
(1.6-4.0)
1.7
(1.1-2.5)
1.4
(0.8, 2.4)
Education
level
0-5 mo
6-11 mo
7.6
(4.7-12.3)
5.1
(2.8-9.3)
Medium
3.5
(2.0-6.1)
2.0
(1.1-3.8)
High
2.7
(1.8-4.1)
1.1
0.5-2.6
Low
The dilemma of HIV transmission during
breastfeeding has refocused our attention
on the importance of breast milk after 6
months as programs struggle to come up
with “Acceptable, Feasible, Affordable,
Sustainable and Safe” feeding alternatives
for HIV-exposed infants
Mozambique targeted evaluation of early
breastfeeding cessation and replacement feeding
options in Manica, Sofala, and Gaza Provinces
PURPOSE:
• To gather information on
early breastfeeding
cessation and replacement
feeding after cessation for
HIV-exposed infants in the
Mozambican context
• To develop and test
recommendations for
improved feeding of HIVexposed infants.
Methodology
-1
• A combination of qualitative and quantitative
methods were used:
– In-depth interviews (67) and focus group discussions (10) with
HIV+ mothers participating in support groups
– IDI (70) and FGD (14) with mothers recruited from the
community and health centers with PMTCT services
– IDI (60) and FGD (21) with other key informants, including
fathers, mothers-in law, health workers and community activists
 Mothers’ interviews included modified food
frequency questionnaire (measuring dietary intake not
feasible)
Note: Purposive sampling methods were used
Methodology
-2
• Linear programming (LP) methods were used to identify
possible feeding recommendations for non-breastfed
infants from 6-8 and 9-11 months. (Nutrisurvey software)
• This approach was recently recommended by WHO but not
previously tested in a program setting (WHO provided TA)
• LP uses locally gathered information on available foods,
consumption patterns, daily food expenditures and prices
(based on market surveys) to identify the combination of
foods needed to meet the nutritional needs of infants at
lowest cost (i.e., meeting “AFASS” criteria)
– Can be used for breastfed and non-breastfed infants
– Nutrient database includes values for energy, protein, and 11
essential vitamins and minerals
Study sites
• Manica
– Chimoio, Catandica
• Sofala
– Beira (Munhava),
Nhamatanda
• Gaza
– Xai-Xai, Macia, Chibuto
HIV, malnutrition, & infant mortality were high in all
study provinces
Adult HIV
prevalence (%)
Stunting in
children < 5
yrs (%)
IMR
(per 1000 live
births)
Manica
19.7
39.0
128
Sofala
26.5
42.3
149
Gaza
19.9
33.6
92
Sources: IDS 2003; MOH 2005 (Ronda 4)
Preliminary Results
Most data come from in-depth
interviews with 137 mothers and the
linear programming
Selected characteristics of study mothers
Age (y) [SD]
-1
25.8 [6.0]
# Children < 5 yrs
2.0 [1.0]
Electricity in home*
26.3%
Refrigerator in home*
17.5%
Unprotected water source
45.3%
Cooks with wood or charcoal (fire)
95.6%
Reads Portuguese**
37.0%
Baby’s father contributes to HH budget
78.4%
Median per capita daily food expenditure
[IQR]
5000 MT
[2500-7500]
$0.20/day
US$ 1= 25,000 meticais (MT)
* Manica mothers less likely to have electricity or fridge (p<0.001)
** HIV+ mothers less likely to read Portuguese (p=0.05)
Selected characteristics of study mothers
Home garden
17.5%
Cultivated field
57.7%
Owns chickens
40.9%
Owns goats
19.0%
Owns oxen
9.5%
Owns other animals (e.g. ducks)
22.6%
Report current food shortage
42.2%
Report receiving food assistance
21.2%
-2
Manica mothers more likely to have cultivated field (p=0.007) & least likely to report
current food shortage.
52% of Gaza mothers reported a current food shortage
HIV+ mothers in Manica & Sofala more likely to receive food assistance (p<0.0001)
Attitudes toward early breastfeeding
cessation (EBC)
• HIV+ mothers and other FGD participants felt that EBC was
good advice to prevent infants from getting HIV, but there are
practical constraints
– Cost/affordability
– Concern that baby would be hungry, become malnourished
– Stigma & discrimination
– “I will have to lie that my milk is not good”
• Most HIV+ mothers (41/67) said they received only general
information about feeding after EBC
– give fruits and a better diet (35)
– give a varied diet (6)
Results of food frequency
% infants regularly consuming different food groups by age
(reported > 4 times/week)
Meat/poultry
Fish
Eggs
Milk
Starches
Legumes
Vegetables
Fruits
Oils/Sugar
100
80
%
60
40
20
0
6-8 m
9-12 m
>12 m
 % consumption increases significantly with infant age for all items except
meat/poultry and eggs which are rarely consumed.
Results of food frequency
% infants 6-12 mo regularly consuming different food groups
by Province
Meat/poultry
Fish
Eggs
Milk
Starches
Legumes
Vegetables
Fruits
Oils/Sugar
100
80
%
60
40
20
0
Manica
Sofala
Gaza
Infant diets are somewhat varied across provinces with Gaza diets having
the lowest variety of foods regularly consumed due to drought/food crisis
Median [IQR] number of food groups
consumed according to infant age
Age
Median
IQR
< 6 mo
1
[0-2]
6-8 mo
3
[2-5]
9-12 mo
4
[2-6]
Preliminary results from linear
programming
6-8 months
9-11 months
Results for infants: Manica & Sofala
 A diet that is adequate in most nutrients (low in iron) can be
developed using local foods ever consumed by > 20% of infants
 However, foods that will need to be eaten daily (or at least several
times a week) include milk, maize/sorghum flour, beans/lentils,
peanuts, dried fish, GLV, carrots/sweet potato, tomato,
papaya/banana, coconut milk oil (8 food groups)
 Estimated cost is ~ $ 0.15-0.21/day for infant only
 Respondents felt that they would probably have to buy these foods
for others in family too – cost implications
 This may not be feasible, however, for the majority of families due
to cost and large number of different foods required to meet most
nutritional needs –further testing is underway
Cost & adequacy of typical diet with & without
breast milk: 6-8 mo (Manica & Sofala)
Diet with breast milk: 2600 MT ($0.11)
Sorghum flour, beans, dried fish, tomato, GLV,
carrots, sweet potato
Diet without breast milk: 5100 MT($0.21)
Sorghum flour, beans, dried fish, tomato, GLV,
sweet potato, papaya, coconut oil, formula,
powdered cows’ milk
Results for infants: Gaza
 An adequate replacement diet can not be developed
using local foods consumed by infants at 6-8 and 9-11
months – food shortage at time of study
 Foods currently consumed are low in iron, zinc, calcium,
& some vitamins
 Early breastfeeding cessation is likely to lead to
significant malnutrition and related risks unless
nutrient-rich supplemental foods are provided requires further testing
Cost & adequacy of typical diet with & without
breast milk: 6-8 mo (Gaza)
Diet with breast milk: 1800 MT ($0.07)
Sorghum & maize flour, GLV, banana, breast milk,
cow’s milk
Diet without breast milk: 5000 MT($0.20)
Sorghum & maize flour, GLV, banana, coconut oil,
cows milk
Locally-produced ready to use nutrient-dense
spreads cost ~ $0.40/100 g in neighboring countries
•
Also called RUTF (ready to use
therapeutic food)
•
If available in Mozambique it would
help both BF & non-BF infants meet
their nutritional requirements > 6 mo
•
LP estimates 37 g of RUTF for non
BF & 19 g of RUTF for BF infants
•
Provide along with usual diet (see
previous slides) – to meet all/most
nutritional needs
•
Cost: $0.07-0.15/d
•
Equals 35-75% of estimated daily
food expenditure - but could be
targeted to children
Diet without breast milk & with
RUTF: 5000 MT /d ($0.20)
Sorghum & maize flour, GLV, coconut
oil, cows milk, RUTF
Conclusions
• Meeting the nutritional needs of infants > 6 months is
challenging taking into account local food availability, variety,
and price – even when breastfed
• Removing BM from the diets of infants > 6 months creates
several challenges, including the need to increase food
expenditure 2-3 fold/day “just to keep even” – other costs too
• Nutrient dense, fortified spreads hold promise for improving
the diets & nutritional status of infants > 6 months – price still
an issue
• Need to test alternative diets – there is a strong desire to use
local foods
Collaborators
Elizabeth Glaser Pediatric AIDS
Foundation
Cathrien Alons, Victorino
Chavane, Ellen Warming, Cathy
Wilfert
Ministry of Health
Sonia Kahn, Atalia Macombe
Save the Children
Katarina Regina, Ronnie Lovich
Health Alliance International
Wendy Johnson, Florencia
Floriano, James Pfieffer
WHO
André Briend
ANSA
Lourdes Fidalgo
Other
Martha Piedrasanta
Academy for Educational
Development
Ellen Piwoz