NATIONAL GUIDELINES ON INFANT AND YOUNG CHILD FEEDING
Dr. Sanjio Borade*
MBBS, DGP, DCH, MCPS Secretary BPNI Amravati Branch *
Introduction

Infant and young child nutrition has been engaging the attention of scientists and planners since long for the very simple reason that growth rate in the life of human beings is maximum during the first year of life and infant feeding practices comprising of both the breastfeeding as well as complementary feeding have major role in determining the nutritional status of the child. The link between malnutrition and infant feeding has been well established. Recent scientific evidence reveals that malnutrition has been responsible, directly or indirectly, for 60% of all deaths among children under five years annually. Over 2/3 of these deaths are often associated with inappropriate feeding practices and occur during the first year of life. Only 35% of infants world-wide are exclusively breastfed during the first four months of life and complementary feeding begins either too early or too late with foods which are often nutritionally inadequate and unsafe. Poor feeding practices in infancy and early childhood, resulting in malnutrition, contribute to impaired cognitive and social development, poor school performance and reduced productivity in later life. Poor feeding practices are, therefore, a major threat to social and economic development as they are among the most serious obstacles to attaining and maintaining health of this important age group.

Optimal Infant and Young Child Feeding practices - especially early initiation and exclusive breastfeeding for the first six months of life - help ensure young children the best possible start to life. Breastfeeding is nature's way of nurturing the child, creating a strong bond between the mother and the child. It provides development and learning opportunities to the infant, stimulating all five senses of the child - sight, smell, hearing, taste, touch. Breastfeeding fosters emotional security and affection, with a lifelong impact on psychosocial development. Special fatty acids in breast milk lead to increased intelligence quotients (IQs) and better visual acuity. A breastfed baby is likely to have an IQ of around 8 points higher than a non-breastfed baby. Breastfeeding is not only important for young child survival, health, nutrition, the development of the baby's trust and sense of security - but it also enhances brain development and learning readiness as well.

As per the scientific evidence available at that time, an age range of 4-6 months for exclusive breastfeeding of young infants was included in the international as well as national code. The age range was misused by the multinational companies which started promoting their products from the third month onwards. The early introduction of complementary foods was resulting in infections and malnutrition.

Various research studies since early 90s have brought out the beneficial effects of exclusive breastfeeding for the first six months on the growth, development and nutrition and health status of the infant and also for the mother. It was revealed that exclusive, breastfeeding not only prevented infections particularly the diarrheal infections in the child but also helped in preventing anemia in child as breast milk has the best bioavailable iron. The appearance of enzyme amylase in the seventh month of the infant was suggestive of desirability of introducing cereal-based foods in the diet of infant after the age of six months.

Early initiation of breastfeeding lowers the mother's risk for excess post-partum bleeding and anemia. Exclusive breastfeeding boosts mother's immune system, delays next pregnancy and reduces the insulin needs of diabetic mothers. Breastfeeding can help protect a mother from breast and ovarian cancers and osteoporosis (brittle bones).

Tenth Five Year Plan Goals:

The Planning Commission recognizing the importance of appropriate infant and young child feeding practices has for the first time included goals for breastfeeding and complementary feeding in the National Nutrition Goals for the Tenth Five Year Plan.

The Tenth Plan has set specific nutrition goals to be achieved by 2007, the major goals are:
  • Intensify nutrition and health education to improve infant and child feeding and caring practices so as to:
    • Bring down the prevalence of under-weight children under three years from the current level of 47% to 40%.
    • Reduce prevalence of severe undernutrition in children in the 0-6 years age group by 50%.

  • Enhance Early Initiation of Breastfeeding (colostrums feeding) from the current level of 15.8% to 50%.
  • Enhance the exclusive breastfeeding rate for the first six months from the current rate of 55.2% (for 0-3 months) to 80%, and
  • Enhance the complementary feeding rate at six months from the current level of 3.5% to 75%.


Objectives of National Guidelines on Infant and Young Child Feeding (NGYCF):

The new norms of Infant and Young Child Feeding i.e., exclusive breastfeeding for the first six months (replacing the 4-6) months age range of earlier guidelines), introduction of complementary foods at six months while continuing breastfeeding up to the age of two years or beyond are not known to all the professionals, instructors from training institutions and the field functionaries in different parts of the country and for want of this critical information, many still continue to advocate the old norms. It has, therefore, been decided to bring out the National Guidelines on Infant and Young Child Feeding, which will replace the earlier National Guidelines on infant feeding brought out by the Food and Nutrition Board, Department of Women and Child Development, Ministry of Human Resource Development, Government of India in 1994 and all other instructional manuals on the subject.

The objectives of National Guidelines on Infant and Young Child Feeding, therefore, are:
  • To advocate the cause of infant and young child nutrition and its improvement through optimal feeding practices nationwide.
  • To disseminate widely the correct norms of breastfeeding and complementary feeding from policy making level to the public at large in different parts of the country in regional languages.
  • To help plan efforts for raising awareness and increasing commitment of the concerned sectors of the Government, national organizations and professional groups for achieving optimal feeding practices for infants and young children.
  • To achieve the national goals for Infant and Young Child Feeding practices set by the Planning Commission for the Tenth Five Year Plan so as to achieve reduction in malnutrition levels in children.

APPROPRIATE INFANT AND YOUNG CHILD FEEDING PRACTICES:
"Breastfeeding is an unequalled 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 fort the health of mother. As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond." - WHO, 2002.

Breastfeeding

Nutritional superiority of breast milk
Modern science and technology has not been able to produce a better food for young infants than mother's milk. Breastfeeding is the best way to satisfy the nutritional and psychological needs of the baby.

The exceptional nutritional quality of human milk has been recognized for a long time. Mother's milk is designed for easy digestion and assimilation. Protein in mother's milk is in a more soluble form which is easily digested and absorbed by the baby. Same is the case with 6ai J to fat and calcium in human milk which are also easily absorbable. The milk sugar - lactose in mother's milk provides ready energy. In addition, a part of it is converted into lactic acid in the intestines which destroys harmful bacteria present there and helps in absorption of calcium and other minerals. The amount of vitamins such as thiamine, vitamin A and vitamin C found in mother's milk depends on the diet of the mother. Under normal conditions, breast milk provides reasonable amounts of these vitamins.

The human milk has inherent anti-infective properties which no other milk has. This protective function of human milk is particularly important in developing countries where there is much exposure to infection. Some of the advantages of breastfeeding are:

Early Initiation of Breastfeeding:
Early initiation of breastfeeding is extremely important for establishing successful lactation as well as for providing 'Colostrum* (mother's first; *4* Iii) to baby. Ideally, the baby should receive the first breastfeed as soon as possible and preferably within half an hour of birth . The newborn baby is very active during the first half an hour and if the baby is kept with the mother and effort is made to breastfeed, the infant learns sucking very fast. This early suckling by the infant starts the process of milk formation in the mother and helps in early secretion of breast milk. In case of caesarean deliveries, newborn infants can be started with breastfeeding within 4-6 hours with support to the mother. Newborn babies should be kept close to their mothers to provide warmth and ensure frequent feeding. This helps in early secretion of breast milk and better milk flow.

It is essential that the baby gets the first breast-milk called colostrums which is thicker and yellowish than later milk and comes only in small amounts in the first few days. Colostrum is all the food and fluid needed at this time - no supplements are necessary, not even water.

During this period and later, the newborn should not be given any other fluid or food like honey, ghutti, animal or powdered milk, tea, water or glucose water, since these are potentially harmful.

The mother, especially with the first birth, may need help in proper positioning for breastfeeding. Breastfeeds should be given as often as the baby desires and each feed should continue for as long as the infant wants to suckle.

Value of Colostrum:
The milk secreted after the child birth for the first few days is called 'Colostrum'. It is yellowish in colour and sticky. It is highly nutritious and contains anti-infective substances. It is very rich in vitamin A. Colostrum has more protein, sometimes up to 10%. It has less fat and the carbohydrate lactose than the mature milk. Feeding colostrums to the baby helps in building stores of nutrients and anti-infective substances (antibodies) in the baby's body. The anti-infective substances protect the baby from infectious diseases such as diarrhea, to which the child might be exposed during the first few weeks after birth. Colostrum is basically the first immunization a child receives from the mother. Some mothers consider this first milk as something dirty and indigestible. Difference in colour and consistency could be possible reasons for such beliefs.

Delayed initiation of breastfeeding is a common practice in the country and this deprives the newborns from the concentrated source of anti-infective properties, vitamin A and protein available in colostrums. In some communities, breastfeeding is started as late as the fifth day for various superstitions and ignorance. In India only 15.8% of the newborns are started with breastfeeding within one hour of birth and only 37.1% within a day of birth.

Late initiation of breastfeeding not only deprives the child of the valuable colostrums, but becomes a reason for introduction of pre-lacteal feeds like glucose water, honey, ghutti, animal or powder milk which are potentially harmful and invariably contribute to diarrhea in the new born. Late initiation of breastfeeding also causes engorgement of breasts which further hampers establishment of successful lactation.

Educating the mothers and the communities about the value of colostrums would help in ensuring that colostrums is not wasted but food to the child.

Exclusive breastfeeding:
Exclusive breastfeeding means that babies are given only breast milk and nothing else - no other milk, food, drinks and not ever water. During the first six months exclusive breastfeeding should be practiced. Breast milk provides best and complete nourishment to the baby during the first six months. The babies who are exclusively breastfed do not require anything else namely additional food or fluid, herbal water, glucose water, fruit drinks or water during the first six months. Breast milk alone is adequate to meet the hydration requirements even under the extremely hot and dry summer conditions prevailing in the country.

It is important to ensure exclusive breastfeeding of all babies as it saves babies from diarrhea and pneumonia. It also helps in reducing specially the ear infections and risk of attach of asthma and allergies. Addition of even a single feed of the animal or powder milk, any other food or even water has two disadvantages, firstly it depresses lactation as child will such less and hence less breast milk will be produced, and secondly addition of any other food or water increases the chances of infections particularly the diarrhea. Recent WHO studies estimate the death rate in babies can go down four times if they are exclusively breastfed for the first six months.

Exclusive breastfeeding provides babies with the best start in life. It makes them smarter with higher intelligence and helps in optimal development. Exclusive breastfeeding is, therefore, extremely important to prevent infections like diarrhea and acute respiratory infections in early infancy and thus reduce infant mortality. It must be remembered that benefits of breastfeeding are reduced if it is not exclusive breastfeeding.

COMPLEMENTARY FEEDING


Importance of Complementary Feeding:
Complementary feeding is extremely essential from six months of age, while continuing breastfeeding, to meet the growing needs of the growing baby. Infants grow at a very rapid rate. The rate of growth at this stage is incomparable to that in later period of life. An infant weighing around 3 kg at birth doubles its weight by six months and by one year the weight triples and the body length increases to one and a half times than at birth. Most of the organs of the body grow rapidly, both structurally and functionally during the early years of life and then later on, the growth slows down. Most of the growth in the nervous system and brain is complete in the first two years of life. In order to achieve optimum growth and development, there is an increased demand for a regular supply of raw material in the form of better nutrition.

Breast milk is an excellent food and meets all nutritional requirements of the baby for the first six months. However, after six months of age, breast milk alone is not enough to make an infant grow well, other foods are also needed. This is because the infant is growing in size and its activities are also increasing. As a result the nutritional needs of the infant increase significantly at this age.

Complementary feeding should be started at six months of age. The purpose of complementary feeding is to complement the breast milk and make certain that the young child continues to have enough energy, protein and other nutrients to grow normally. It is important that breastfeeding is continued up to the age of two years or beyond as it provides useful amounts of energy, good quality protein and other nutrients.

Adequate complementary feeding from six months of age while continuing breastfeeding is extremely important for sustaining growth and development of the infant. Active feeding styles for complementary feeding are also important. Appropriate feeding styles can provide significant learning opportunities through responsive care-giver interaction, enhancing brain development in the most crucial first three years.

First food for the baby
The staple cereal of the family should be used to make the first food for an infant. Porridge can be made with suji (semolina), broken wheat, atta (wheat flour) ground rice, ragi, millet etc, by using a little water or milk, if available. Roasted flour of any cereal can be mixed with boiled water, sugar and a little fat to make the first complementary food for the baby and could be started on the day the child becomes six months old. Adding sugar or jaggery and ghee or oil is important as it increases the energy value of the food. In the beginning, the porridge could be made a little thinner but as the child grows older the consistency has to be thicker. A thick porridge is more nutritious than a thin one. In case a family can not prepare the porridge for the infant separately, pieces of half chapatti could be soaked in half a cup of milk or boiled water, mashed properly and fed to the baby after adding sugar and fat. Soaked and mashed chapatti could be passed through a sieve so as to get a soft semi-solid food for the infant.

Fruits like banana, papaya, chikoo, mango, etc could be given at this age in a mashed form. Infants could also be given reconstituted instant infant foods (preparation of which is discussed a little later) at this age.

Traditional foods for infants
Once the child is eating the cereal porridge well, mixed foods including cooked cereal, pulse and vegetable(s) could be given to the child. Most traditional foods given to infants in different parts of the country are examples of mixed foods like khichdi, dalia, suji kheer, upma, idli, dokhla, bhaat-bhaji etc. Sometimes traditional foods are given after a little modification so as to make the food more suitable for the child. For instance, mashed idli with a little oil and sugar is a good complementary food for the infant. Similarly bhaat can be made more nutritious by adding some cooked dal or vegetable to it. Khichdi can be made more nutritious by adding one or two vegetables in it while cooking.

Modified family food
In most families, there is a cereal preparation in the form of roti or rice and a pulse or a vegetable preparation. For preparing a complementary food for the infant from the foods cooled for the family, a small amount of dal or vegetable preparation should be separated before adding spices to it. Pieces of chapatti could be soaked in half a katori of dal and some vegetable, if available. The mixed food could be mashed well and fed to the baby after adding a little oil. If necessary be, mixture could be passed through a sieve to get a semi-solid paste. Thus, rice or wheat preparation could be mixed with pulse and/or vegetable to make a nutritious complementary food for the infant. Modifying family's food is one of the most effective ways of ensuring complementary feeding of infants.

Instant Infant Foods
Infant food mixes can be made at home from foodgrains available in the household. These mixes can be stored at least for a month and enable frequent feeding of infants. These are sattu-like preparations which is quite familiar in the Indian community. One can take three parts of any cereal (rice/wheat) or millet (ragi, bajra-jowar, one part of any pulse (moong/channa/arhar) and half part of groundnuts or white til, gingelly seeds) if available. The food items should be roasted separately, ground, mixed properly and stored in airtight containers. For feeding, take two tablespoons of this infant food mix, add boiled hot water or milk, sugar or jaggery and oil/ghee and mix well. Cooked and mashed carrot, pumpkin or green leafy vegetables could be added to the porridge, if available. The infant can be fed with this food whenever freshly cooked food is not available in the family. The infant food mix could also be made into preparations like halwa, burfi, upma, dalia etc, and given to the child.

Protective foods
Besides modified family food and reconstituted infant food mixes, protective foods like milk, curd, lassi, egg, fish, fruits and vegetables are also important to help in the healthy growth of the infants. Green leafy vegetables, carrots, pumpkin and seasonal fruits like papaya, mango, chikoo , banana etc are important to ensure good vitamin A and iron status of the child.

Baby needs all foods from six months namely cereals, pulses, vegetables particularly green leafy vegetables, fruits, milk and milk products, egg, meat and fish if non-vegetarian, oil/ghee, sugar and iodized salt in addition to breastfeeding. A diversified diet of the infant along with breastfeeding will also improve the micronutrients' status of the child.

Energy Density of Infant Foods
Low energy density of complementary foods given to young children and low frequency of feeding result in inadequate calorie intake and thus the malnutrition. Most of the foods are bulky and a child cannot eat more at a time. Hence, it is important to give small energy dense feeds at frequent intervals to the child with a view to ensure adequate energy intake by the child.

Energy density of foods given to infants and young children can be increased in four different ways:
By adding a teaspoonful of oil or ghee in every feed

  1. By adding sugar or jaggery to the child's food

  2. By giving malted foods
    Malting reduces viscosity of the foods and hence child can eat more at a time. Malting is germinating whole grain cereal or pulse, drying it after germination and grinding. Infant food mixes prepared after malting the cereal or pulse will provide more energy to the child. Flours of malted food when mixed with other foods help in reducing the viscosity of that food. Amylase Rich Flour (ARF) is the scientific name given to flours of malted foods and must be utilized in infant foods.

  3. By feeding thick mixtures
    Thin gruels do not provide enough energy. A young infant particularly during 6-9 months requires thick but smooth mixtures as hard pieces in the semi-solid food may cause difficult if swallowed. The semi-solid foods for young infants can be passed through a sieve by pressing with a ladle to ensure that the mixed food is smooth and uniform without any big pieces or lumps.


Frequency of Feeding
Infants and young children need to be fed 5-6 times a day in addition to breastfeeding. It must be remembered that inadequate feeding of infants and young children during the first two years is the main cause of malnutrition.

CONTINUED BREASTFEEDING
Breastfeeding must be continued up to the age of two years or beyond. Continuing breastfeeding while giving adequate complementary foods to the baby provides all the benefits of breastfeeding to the baby. In other words, the child gets energy, high quality protein, vitamin A, anti-infective properties and other nutrients besides achieving emotional satisfaction from the breastfeeding, much needed for optimum development of the child. Breastfeeding especially at nigh ensures sustained lactation.

In the beginning when the complementary foods are introduced after six months of age, the complementary food should be fed when the infant is hungry. As the child starts taking complementary foods well, the child should be given breastfeeding first and then the complementary food. This will ensure adequate lactation.

Active Feeding
Adopting caring attitude while feeding the baby like talking to the child, playing with the child stimulates appetite and development. 1-2 year old child should be given food on a separate plate and encouraged to eat on its own. Eating at the same time and at the same place also helps in improving appetite and avoids distractions.

Growth Monitoring and Promotion (GMP)
Weighing the child regularly and plotting the weight on the health card is an important too to monitor the growth of the baby. Infants and young children should be weighed every month in the presence of their mothers and the growth status of the child should be explained to the mother. The growth chart kept in a plastic jacket could be entrusted to the mother. If the child is having malnutrition, the mothers should be advised to provide additional food to the child every day. Malnourished children should be followed up at home and mothers encouraged to come and ask questions regarding the feeding and care of the child.

Ensuring Safety of Complementary Foods
Careful hygienic preparation and storage of complementary foods is crucial to prevent contamination. Personal hygiene plays an important role in feeding infants. If cleanliness is not observed, complementary feeding may do more harm than good to the child by introducing infections to the infant. It is, therefore, important that all foods prepared for young infants are handled in a way that they are free from any germs. Some of the considerations while preparing foods for infants are as under:
  • Hands should be washed with soap and water before handling the food as germs that cannot be seen in dirty hands can be passed on to the food.

  • Utensils used should be scrubbed, washed well, dried and kept covered.

  • Cooking kills most germs. The foods prepared for infants should be cooked properly so as to destroy harmful bacteria present, if any.

  • After cooking, handle the food as early as possible and keep it in a covered container protected from dust and flies.

  • Cooked foods should not be kept for more than one to two hours in hot climate unless there is a facility to store them at refrigeration temperature.

  • The hands of both mother and child should be washed before feeding the child.

Utilizing the available Nutrition and Health Services
There are a number of nutrition and health services available for young children in almost all places. The people in the community should be informed about various services which are available for children in the village, at the sub-centre, at the Primary Health Centre, under Reproductive and Child Health (RCH) Programme, Integrated Child Development Services (ICDS) Scheme, etc. Every effort should be made to encourage the community members to make use of these facilities so as to promote child health.

Feeding during and after illness
During the weaning period, i.e., from six months to two years of age, young children often suffer from infections like diarrhea, measles, cold, cough, etc. If their diet had been adequate, their symptoms are usually less severe than those in an undernourished child. A sick child needs more nourishment, so that he could fight infections without using up nutrient reserves of his body. However, a child may lose appetite and may refuse to eat, but the child needs adequate nutrition to get better from illness, breastfeeding and complementary feeding should continue during illness. Restriction or dilution of food should be discouraged. Tune and care must be taken to help an ill child eat enough food. The infant can be encouraged to eat small quantities of food but more frequently and by offering foods the child likes to eat.

FEEDING IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES


Malnourished infants
Infants and young children who are malnourished are most often found in environments where improving the quality and quantity of food intake is particularly problematic. To prevent a recurrence and to overcome the effects of chronic malnutrition, these children need extra attention both during the early rehabilitation phase and over the longer term. Continued frequent breastfeeding and, when necessary, relactation are important preventive steps since malnutrition often has its origin in inadequate or disrupted breastfeeding.

Nutritionally adequate and safe complementary foods may be particularly difficult to obtain and dietary supplements may be required for these children. Mothers of malnourished children could be invited in a camp and provided with a fortnight's ration of roasted cereal-pulse mixes with instructions. The children could be followed up every fortnight for growth monitoring, health check up and supply of instant food ration for a period of three months.

When malnourished children improve with appropriate feeding, they themselves would become educational tools for others.

Preterm or Low Birth Weight Infants
Breast milk is particularly important for preterm infants and babies with low birth weight (newborn with less than 2.5 kg weight) as they are at increased risk of infection, long term ill health and death.

Keep preterm or low birth weight baby warm. Practice Kangaroo care. Kangaroo care is a care given to a preterm baby in which baby is kept between the mother's breast for skin to skin contact as long as possible as it simulates intrauterine environment and growth. This helps the baby in two ways.
  1. The child gets the warmth of the mother's body, and
  2. The baby can suck the milk from the mother's breasts as and when required. Such babies may need to suck more often for shorter duration. If the baby is not able to suck, expressed breast milk may be fed with katori or tube.

The unique composition of preterm milk with its high for preterm babies. Preterm baby should be fed every two hourly during the day and night.

Feeding During Emergencies
Infants and young children are among the most vulnerable victims of natural or human induced emergencies. Interrupted breastfeeding and inappropriate complementary feeding heighten the risk of malnutrition, illness and mortality. Uncontrolled distribution of breast milk substitutes, for example in refugee settings, can lead to early and unnecessary cessation of breastfeeding.

Emphasis should be on protecting, promoting and supporting breastfeeding and ensuring timely, safe and appropriate complementary feeding. Provide infant formula to those identified for need. Effort should be made to reduce ill effects of artificial feeding by ensuring adequate, sustainable supplies of breast milk substitutes, proper preparation of artificial feeds, supply of safe drinking water, appropriate sanitation, adequate cooking utensils and fuel. Pregnant and lactating women should receive priority in food distribution and should be provided extra food in addition to general ration. Complementary feeding of infants aged 6 months to 2 years should receive priority. Donated food should be appropriate for the age of the child. Immediate nutritional and care needs of orphans and unaccompanied children should be taken care of.

Feeding in Maternal HIV
The HIV pandemic and the risk of mother to child transmission of HIV through breastfeeding pose unique challenges to the promotion of breastfeeding, even among unaffected families. The absolute risk of HIV transmission through breastfeeding for more than one year - globally between 10% and 20% - needs to be balanced against the increased risk of mortality and morbidity when infants are not breastfed.

All HIV infected mothers should receive counseling, which should include provision of general information about meeting their own nutritional requirements, and about the risks and benefits of various feeding options, and specific guidance in selecting the option most likely to be suitable for their situation. The manifold advantages of breastfeeding even with some risk of HIV transmission should be explained to the HIV positive mothers.

The dangers of mixed feeding of infants should be explained to the HIV infected mothers. Sometimes mothers may chose to artificially feed the baby, but under some social pressures they also breastfeed the child. An artificially fed baby is at less risk than the baby who receives mixed feeding i.e., both breastfeeding and artificial feeding. The aim of the counseling for feeding infants in maternal HIV should, therefore, be to avoid mixed feeding. All breastfeeding mothers should be supported for exclusive breastfeeding up to six months. If the woman chooses not to breastfeed, she should be provided support for artificial feeding to make it safe.

Content of IYCF:
Thus from this information we find that content of IYCF is very broad basic but often neglected and forgotten. Let us we all get learned about IYCF and fight against PEM.
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