Inctan Jounal of Communty Medicine Vol. XXV, No.1, Jan--Mar., 2000, Continuing Medical Education LACTATION MANAGEMENT - NEED FOR TRAINING IN INDIAN CONTEXT D.K. Taneja, J.P. Dadhich” Deptt of PSM, Maulana Azad Medical College. New Dethi. “Sunder Lal Jain Hospital, Delhi ‘The advantages of breast feeding the body are too well known to be discussed, It isa well established fact that breast milk alone is sufficient for first 4-6 months of life. Supplemental water is not required even in hot climates during the first four months as breast milk provides for water requirement also'". Supplemental water in fact reduces the intake of breast milk’, The practice of exclusive breastfeeding the babies upto 4-6 months is associated with lower incidence of diarrhoea and respiratory illness and it also protects against weight loss due to such illnesses". Our current concept of appropriate timing. for introduction of complimentary food is based on theoretical calculation of energy requirements of the baby and energy provision by breast milk, ‘Thus itis assumed that when the energy intake from breastmilk falls below these theoretical ‘requirements, additional energy sources need to be offered". For infants 6-12 months of age WHO recommends 98 koalvkg/lay, However, breastfed infants typically consume less energy’. This interesting phenomenon seems to be a voluntary self regulation of energy intake by breastfed infans’ This lower energy intake by breast fed infants does not lead to any functional impairment", These reports regarding lower energy intake by breastfed infants have lead to recommend initiation of complimentary foods ater 4-6 months of life, National bodies like deptt. of Women and Child Development, Govt of India, Indian Academy of. Pediatrics, American Academy of Pediatrics and Inwerational declarations like the The World Summit for Children and Innocent declaration (1990) have issued similar recommendations"''", Similar growth pattern of tweasifed infants from affluent as well as. poor communities'’ further substantiates the basis of these recommendations and also proves that lactation performance is not different in affluent or poor. Early introduction of complimentary foods simply replaces breast milk without contributing to total energy intake and growth'*". Studies indicate it to be harmful and associated with poor nutritional status". Although the practice of breast feeding the babies is nearly universal in developing countries including India but harmful feeding practices are widely prevalent. These include late initiation ‘of breast feeding which is associated with practice of prelacteal feeds, early introduction of animal or formula rmlk, infant foods, water and other fluids often using bottle to feed the infants. This situation is attributable to ignorance, misbelicfs. cultural practices. aggressive promotion of infant milk substitutes and infant foods which undermine the confidence of mothers in adequacy of breast milk and also these being considered status symbol. The training of doctors, nurses and paramedicals is also at fault ‘due (o deficiencies in the curricula and the text books. AS a result instead of reassuring and guiding the mothers for successful breast feeding, they often advise top milk on est pretext. Results of multi indicator cluster surveys covering 17 states in India are startling. Only 11 infants were put to breast within one hour of birth. This percentage increased to just 30% by four hours and 61% by 24 hours”. Although there is no standard definition of late initiation of breast feeding, presuming a cut off point of four hours after delivery means that 70% infants in India are being put to breast late. Against the recommendation of exclusive breast feeding, ic. giving breast milk only and not even water till first 4-6 months of life studies from India show alarming trends. NFHS (1992-93) revealed that only about half of 0-3 ‘months old babies were exclusively breastfed. More than three fourth of infants (79.2%) in Delhi were given water or ‘other fluids like top milk or fruit juice by three months of age and even 60.8% introduced these within first month”.Children prematurely introduced to top feeds are commonly (80%) given dilute animal milk using feeding botles”. thus exposing them to the risk of diarthoca and malnutrition, Most common reason cited hy mothers for carly introduction of top feeds is inadequate milk, although itis 4 well known fact that almest all mothers can produce enough milk if they want to and provided the baby suckles in a good position and breastfeeds often enough”. Often doctors and health workers accept what & mother says and advise her to give supplements. This is duc to deficiencies in their training. An enquiry into undergraduate and postgraduate medical and paramedical euricula, coramon text books of Paediatrics, Preventive and Social Medicine and Obstetrics reveal adequate stress on advantages of breast milk. However, these lack in approach to support breast feeding ic. analyse causes of complaint by mothers ‘that their milk is madequate and counsel accordingly. Even knowledge about feeding during common problems such as sore or cracked nipples flat or inverted nipples, mastitis and breast abscess is offen incorrect among the dociors and paramedical workers. All this strongly points towards need for introduction of lactation management in the undergraduate and postgraduate medical curricula and curricula for nursing and other paramedical workers. References: 1. Almoth SG: Water requirement of breast-fed infants ina hot climate. Am J Clin Nute 1978, 31: 1154-57. 2. Brown KH, Kanashiro HC. del Aguila R, Guillermo LR, Black RE: Milk consumption and hydration status of exclusively breast-fed infants in a warm climate. J Pediatr 1986, 108: 677-80. 3. Sachdev HPS, Krishna Joyti, Puri RK, Salyanarayana L and Kumar Shiv: Water supplementation in exclusively breast fed infants during summer in tropics. Lancet 1991, April 20: 337(8747): 929-33, 4. Breast feeding and diarrhoea, Pediatrics, 1990 Dec, 86(6): 874-82. 5. Lenore J Launer, Jean-Pierre Habicht and Sri Kardjati. Am J Epid 1990 Feb, 13(2); 322-31. ” 6 I 4, 15, Ineian Joumal of Community Medicine Vol. XXV, No.1, Jan-Mar, 2000 Brown KH. Kanashiro HC, Dewey KG: Optimal complementary feeding practices 10 prevent childhood malnutrition in developing countries. Food & Nutrition Bulletin 1995, 16(4): 320-39, Heinig MJ, Nommsen LA. Peerson JM, Lonnerdal B, Dewey KG: Energy and protcin intakes of breastfed and formula fed infants during the first year of life and their association with growth velocity; the DARLING study, Am J Clin Nutrition 1993; 58: 152-61. Dewey KG. Lonnerdal B: Infant self regulation of breastmilk intake. Acta Pediatr Scand 1986: .75: 893-98. ‘World Health Organization. Contaminated food: A ‘major cause of diarrhoea and associated malnutrition ‘among infants and young children. Facts about infant feeding 1993; 3: 2-4 Salmenpera L, Perheentupa J, Siimes MA: Exclusively breastfed healthy infants grow slower than reference infants. Pediatr Res 1985: 19: 307-12. ‘American Academy of Pediatrics work group on breastfeeding. Breastfeeding and the use of human milk, Pediatrics 1997; 100(6): 1-5. Borresen HC: Rethinking current recommendations to introduce solid food between four and six months 10 exclusively breastfed infants. 1 Hum Lact 1995: 1G»: 201-4 National guidelines on infant feeding. Food and nutrition board, Department of Women and Child Development. Govt. of India, 1995, Dewey KG, Person JM, Heinig MJ et al: Growth patiern of breastfed infants in affluent (US) and poor (Peru) communities: implications for timing of complementary feeding, Am J Clin Nutr 1992: $6(6): 1012-16, Cohen RJ, Brown KH, Canahuati J, Rivera LL, Dewey KG: Effects of age of introduction of complementary foods on infant breasimilk intake, total energy intake and growth - a randomized intervention study in Honduras. Lancet 1994: 344: 288-93.Garza C, Butte NF: Energy intake of human milk-fed infants during the frst year. J Pediatr 1990; 117: S 12431 Stuff JE, Garza C, Boutte Cet al: Sources of variance in milk and caloric intakes in breastfed infants: implications for lactation study design and imerprettion. Am J Clin Nutr 1986: 43: 361-66. Davies-adetugbo A, Adetugbo K: Effect of early complementary feeding on nutritional stats in term infants in rural Nigeria. Nutrition & Health 1997: 12(1):25-31. Haider R, Islam A, Kabir 1, Hable D: Early complementary feeding is associated with low rutritional stam of young infants recovering from Indian Journal of Commurity Medicine Vol. XXV, No.1, Jan-Mar, 2000 2. diarrhoea. Trop Pediatr 1996: 43(2y: 170-72. ‘Summary of findings of MICS in India 1995-97, draft National Report, UNICEF ICO, 1998: 8.9. ‘Aggarwal A. Arora S, Patwari AK: Breastfeeding among urban women of low socio-economic status-factors influencing introduction of supplemental feeds before four month of age, Indian Pediatr 1998, 35: 269-73. King Felicity $: Later problems and continuing to feed in helping mothers to breastfeed. Indian ‘Adaptation by R.K. Anand. Acash Publications, Bombay 1994: 59. LIFE MEMBERSHIP OF INDIAN ASSOCIATION OF PREVENTIVE AND SOCIAL MEDICINE We are happy to announce that the number of LIFE MEMBERS of our Association has gone upto 1231 (as of March., 2000). All new LIFE MEMBERS have been individually informed about their "L” numbers. 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