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Recently, a great deal of attention has deservedly been given to the need for appropriate and adequate complementary f

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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Recently, a great deal of attention has deservedly been given to the need for appropriate and adequate complementary f

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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. There is an increased risk of death if not breastfed > 6 months, particularly amongst infants of mothers who are more disadvantaged (WHO, Lancet, 2000)

  7. 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

  8. 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.

  9. 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

  10. 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

  11. Study sites • Manica • Chimoio, Catandica • Sofala • Beira (Munhava), Nhamatanda • Gaza • Xai-Xai, Macia, Chibuto

  12. HIV, malnutrition, & infant mortality were high in all study provinces Sources: IDS 2003; MOH 2005 (Ronda 4)

  13. Preliminary Results Most data come from in-depth interviews with 137 mothers and the linear programming

  14. 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)

  15. 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)

  16. 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)

  17. 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.

  18. 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

  19. Median [IQR] number of food groups consumed according to infant age

  20. Preliminary results from linear programming 6-8 months 9-11 months

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

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