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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.

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The very important contribution of breast milk to energy and other nutrient requirements beyond 6 months of exclusive breastfeedingSCN working group on breastfeeding & complementary feedingEllen PiwozAcademy for Educational DevelopmentMarch 14, 2006

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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)

2003

2002

2005

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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

Dewey KG & Brown KH (2003) Food Nutr Bull 24: 5-28

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Breast milk is a major source of other nutrients in the diets of infants > 6 months – particularly in developing country settings

Adapted from Kimmons et al, 2005, J Nutr 135: 444-451

continued breastfeeding also provides other benefits to families and infants
Continued breastfeeding also provides other benefits to families and infants

Median durations of breastfeeding, post-partum amenorrhea and abstinence in selected African countries

(DHS stat-compiler)

  • Continued transfer of many anti-infective agents/immune protective agents (sIgA, lactoferrin, lysozyme, IFN g, oligosaccharides, cytokines, etc.)
  • Birth spacing
  • Means for comforting infants
  • Protection against severe illness & death
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There is an increased risk of death if not breastfed > 6 months, particularly amongst infants of mothers who are more disadvantaged (WHO, Lancet, 2000)

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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

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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 HIV-exposed 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)

Methodology -1

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

Methodology -2
study sites
Study sites
  • Manica
    • Chimoio, Catandica
  • Sofala
    • Beira (Munhava), Nhamatanda
  • Gaza
    • Xai-Xai, Macia, Chibuto
hiv malnutrition infant mortality were high in all study provinces
HIV, malnutrition, & infant mortality were high in all study provinces

Sources: IDS 2003; MOH 2005 (Ronda 4)

preliminary results

Preliminary Results

Most data come from in-depth interviews with 137 mothers and the linear programming

selected characteristics of study mothers 1
Selected characteristics of study mothers-1

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 2
Selected characteristics of study mothers-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)

Attitudes toward early breastfeeding cessation (EBC)
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Results of food frequency % infants regularly consuming different food groups by age (reported > 4 times/week)
  • % 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
Results of food frequency % infants 6-12 mo regularly consuming different food groups by Province
  • Infant diets are somewhat varied across provinces with Gaza diets having the lowest variety of foods regularly consumed due to drought/food crisis
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

Results for infants: Manica & Sofala
cost adequacy of typical diet with without breast milk 6 8 mo manica sofala
Cost & adequacy of typical diet with & without breast milk: 6-8 mo (Manica & Sofala)

Diet with breast milk: 2600 MT ($0.11)

Diet without breast milk: 5100 MT($0.21)

Sorghum flour, beans, dried fish, tomato, GLV, carrots, sweet potato

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

Results for infants: Gaza
cost adequacy of typical diet with without breast milk 6 8 mo gaza
Cost & adequacy of typical diet with & without breast milk: 6-8 mo (Gaza)

Diet with breast milk: 1800 MT ($0.07)

Diet without breast milk: 5000 MT($0.20)

Sorghum & maize flour, GLV, banana, coconut oil, cows milk

Sorghum & maize flour, GLV, banana, breast milk, cow’s milk

locally produced ready to use nutrient dense spreads cost 0 40 100 g in neighboring countries
Locally-produced ready to use nutrient-dense spreads cost ~ $0.40/100 g in neighboring countries

Diet without breast milk & with RUTF: 5000 MT /d ($0.20)

  • 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

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

Conclusions
collaborators
Elizabeth Glaser Pediatric AIDS Foundation

Cathrien Alons, Victorino Chavane, Ellen Warming, Cathy Wilfert

Health Alliance International

Wendy Johnson, Florencia Floriano, James Pfieffer

ANSA

Lourdes Fidalgo

Academy for Educational Development

Ellen Piwoz

Ministry of Health

Sonia Kahn, Atalia Macombe

Save the Children

Katarina Regina, Ronnie Lovich

WHO

André Briend

Other

Martha Piedrasanta

Collaborators