BREAKING THE BARRIERS TO BREASTFEEDING
Dr. D. GUNASINGH *
Pediatrician, Institute of Child Health and Hospital for Children Egmore, Chennai, Secretary IAP-TNSC. *
Introduction

Breastfeeding

forms the best food for newborn in the initial months of life. Although much stress is laid on breastfeeding, its practice is confounded by a large number of barriers. According to WHO global strategy for infant and young child feeding, "Malnutrition has been responsible directly or indirectly for 60% of the 10.9 million deaths annually among children under five, 2.42 million of these (roughly one quarter) deaths are in India alone."

Recommended Optimal Infant and Young Child Feeding Practices:

  • Starting breastfeeding immediately after birth, preferably within half an hour
  • Exclusive breastfeeding for the first six months
  • Continued breastfeeding for two years or beyond
  • Introducing appropriate and adequate complementary feeding after 6 months

In India, 24.67 million children are born every year. 1.71 million die by the age of one year. There are 115 million children under the age of 5 years. Out of these about 60 million are underweight or stunted, because of not enough breast milk intake in early childhood and not enough appropriate high quality food with good nutritional value after six months. Malnutrition makes the children sick more often and has profound negative consequences on physical development and mental health of children. National Family Health Survey 1998-99 showed the percentage of mothers who started breastfeeding within one hour as 15.8% in India where as in Tamil Nadu it is 50.3%. The percentage of children aged 0-3 months who are exclusively breastfed in India is 55.2 where as in Tamil Nadu it is 48.3%. The percentage of children aged 6-9 months who received breast milk and solid food in India is 33.5% whereas in Tamil Nadu it is 55.4%. The percentage of children aged <12 months who are bottle fed in India is 15.9% whereas in Tamil Nadu it is 34.1%. A study conducted at Chengalpattu by BPNI shows initiation of breastfeeding within 1 hour in 71%. Prelacteal feed was given in 20.8%, exclusive breastfeeding for six months in 19.8% and complementary feeding in 74%. Study conducted at Thiruvallur and Vellore showed that inspite of 90% of the mothers being available to breastfeed and 70% of the mothers had been given breastfeeding counseling; only 22% of the babies were given exclusive breastfeeding till the end of 6 months.

My study at Institute of Child Health and Hospital for Children in 2004 showed that among the 200 mothers, only 62 (31%) mothers practiced exclusive breastfeeding till the end of 6 months. We found that 99 (49.5%) mothers knew about the recommended duration of exclusive breastfeeding out of whom only 19 (19.2%) mothers practiced exclusive breastfeeding till 6 months of age. 78% of the mothers started other food before 6 months of age because of maternal perception of insufficient milk supply. The advice for starting top feeds before 6 months of age was given by doctors in 51% of cases while 45% of mothers took the advice from their family members, another 2% started top feeds on their own and the rest 2% followed the advice of their neighbours. For the first time, Government of India has included State-specific goals in its 10th Five Year Plan to improve infant and young child feeding practice to reduce IMR and malnutrition. The Five Year Plan aims to improve exclusive breastfeeding rate to 80% during first 6 months from the current level of around 41% and increase the rate of complementary feeding from 33.5% to 75%. According to Lancet 2003 series on child survival, 13% of under five child deaths can be saved by achieving 90% coverage of exclusive breastfeeding for the first 6 months Breastfeeding promotion is the most cost effective programme in the child survival programme.

BARRIERS TO BREASTFEEDING:

  1. HEALTH CARE PROFESSIONALS:

    1. Lack of training
    2. Lack of knowledge of duration of exclusive breastfeeding
    3. Lack of motivation to undergo training
    4. Medical education :Lack of lactation management training in the curriculum of medical and nursing courses.
    5. Infant Milk Substitute Act (IMS Act): Inspite of IMS Act, various food companies still sponsor openly or secretly many organizations and individuals. This results in the unhealthy practice of medical practitioners being bound to prescribe and promote infant formula.
    6. Private Practice
    7. Soft corner for cow's milk: When the child is given cow's milk by paladai or spoon, the doctors do not bother to motivate the mother to breastfeed.

  2. MOTHER:
    1. Antenatal counseling
    2. Lack of knowledge
    3. No enough milk
    4. Working mother
    5. LSCS
    6. Misperception about baby's well being
    7. Illness in the mother
    8. Place of delivery
    9. Beauty and Breastfeed : Some mothers may feel breastfeeding may affect their beauty.

  3. BABIES:
    1. Pre-term babies
    2. Child illnesses
    3. Multiple deliveries
    4. Orphans
    5. Child born to HIV mother

  4. FAMILIES:
    1. Lack of knowledge
    2. Lack of motivation to support the mother to breastfeed
    3. Belief that colostrum is bad for the new born

BREAKING THE BARRIERS TO BREASTFEEDING:

  1. HEALTH CARE PROFESSIONALS (HCP):
    1. Training
    2. Duration of exclusive breastfeeding
    3. Medical Education: Lactation management should be a vital aspect in the curriculum of medical, nursing and paramedical courses both at the undergraduate level and at the postgraduate level.
    4. School and collegiate education: Lactation management should be part of the syllabus at schools and colleges.
    5. (IMS Act of) Cow's milk

  2. MOTHER:
    1. Antenatal counseling
    2. Post-natal
    3. LSCS
    4. Immunization visit
    5. Working mother: Mothers should be encouraged to take six months off from their work to facilitate exclusive breastfeeding. If it is not possible, mothers should be encouraged to shift their residence near work place so that they can effectively make use of the lactation breaks. Employers should be encouraged to have crèches in their work places to facilitate breastfeeding. If the above measures are not possible, then the mother should be trained to express breast milk which can be kept at room temperature for 6 to 8 hours. The caretaker can feed the baby with EBM.
    6. Illness in the mother: In most illnesses, the mothers can breastfeed the child. In special situations, it is better to take the help of a lactation management professional.

  3. BABIES:
    1. Preterm:
      Most of the preterm babies can suck at the breast. If not, EBM can be fed with paladai. In the event of difficulty in swallowing, EBM can be given through a nasogastric tube
    2. Infants with special needs:

      Most of these infants can be breastfed. Special situations can be tackled with the help of the lactation management consultant.
    3. HIV and Breastfeeding:

      It is indeed a challenging situation, which should be handled by professionals.
    4. Multiple deliveries:

      Twins can be successfully breastfed.

  4. FAMILIES:
    All family members including mother, husband and in-laws should be sensitized to breastfeeding in the antenatal visits, immediate postnatal visits and in all subsequent visits.
Community Level:
  1. Training of TBA, AWW, and CHW on the correct method of breastfeeding.
  2. In IMNCI training, breastfeeding counseling is the important component of this strategy. Hence all HCW should be trained in IMNCI.
  3. Self help groups, volunteers, village leaders, teachers, religious leaders and politicians could be motivated to spread messages on the exclusive breastfeeding.
  4. Mother support groups should be formed with the help of a successfully breastfeeding mother, working mothers so that they share their experiences with each other.
  5. Organization of discussions on breastfeeding by AWW in community so that mothers get the correct information on breastfeeding.
  6. Arrangement of crèches for working women at work places where they can breastfeed their babies.

Government Level:
  1. Curriculum of the medical, nursing, paramedical courses should have lactation management.
  2. Doctors in Government service and private practice should be given special training in breastfeeding counseling.
  3. Optimal infant and young child feeding should be included in the curriculum of schools and colleges.
  4. IMS ACT should be strictly implemented.
Conclusion
Thus, a

paradigm shift

is needed to make meaningful progress towards substantially more and longer breastfeeding for infants in India. The new paradigm must include more than statements from organizations and individuals that breastfeeding is to be encouraged. IAP should work more actively and take all efforts to break the barriers to breastfeeding. The

recommended optimal infant and young child nutrition

is to become a social norm. The non-breast milk is only reserved for children in orphanages and with specific indication. Increase in initiation and duration are needed to realize the health, nutritional, immunological, psychological, economical, and environmental benefits of breastfeeding. Appropriate lactation management is a critical component of successful breastfeeding for healthy women.

Lactation support and management

is even more important in women and children with special needs caused by physical or developmental disability, disease, or limited resources. IAP members have a responsibility to support breastfeeding through appropriate education and training, advocacy, and legislative action through collaboration with other professional groups and through research to eliminate the barriers to breastfeeding.
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