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 PiwozAcademy for Educational

Development

March 14, 2006

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)

2002 2003

2005

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

Contribution of breast milk energy intake to TOTAL ENERGY REQUIREMENTS (+2 SD) of children 6-23 mo

6-8 mo 9-11 mo 12-23 mo

54%(average)

44%(average)

31%(average)

28-79%(range)

18-70%(range)

8-54%(range)

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

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

% Contribution of BM to total intake of nutrients by Bangladeshi

inf ants

020406080

100

% c

ontr

ibut

ion

of B

M

6-8 mo 9-11 mo

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

Continued breastfeeding also provides other benefits to families and infants

• Continued transfer of many anti-infective agents/immune protective agents (sIgA, lactoferrin, lysozyme, IFN oligosaccharides, cytokines, etc.)

• Birth spacing

• Means for comforting infants

• Protection against severe illness & death

0

5

10

15

20

25

30

35

Kenya '03

Rwanda '00

South Africa '98

Tanzania '99

Zimbabwe '99

mon

ths

Breastf eeding Amenorrhea Abstinence

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

countries

(DHS stat-compiler)

There is an increased risk of death if not breastfed > 6 months, particularly amongst

infants of mothers who are more disadvantaged (WHO, Lancet, 2000)

OVERALL 0-1 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo

OR(95% CI)

4.2(2.8-6.3)

3.6(2.4-5.5)

2.5 (1.6-4.0)

1.7(1.1-2.5)

1.4(0.8, 2.4)

Education level

0-5 mo 6-11 mo

Low 7.6(4.7-12.3)

5.1 (2.8-9.3)

Medium 3.5 (2.0-6.1)

2.0(1.1-3.8)

High 2.7 (1.8-4.1)

1.10.5-2.6

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

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)

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

Study sites

• Manica– Chimoio, Catandica

• Sofala– Beira (Munhava),

Nhamatanda

• Gaza– Xai-Xai, Macia,

Chibuto

HIV, malnutrition, & infant mortality were high in all study provinces

Adult HIV prevalence

(%)

Stunting in children < 5

yrs (%)

IMR(per 1000 live

births)

Manica 19.7 39.0 128

Sofala 26.5 42.3 149

Gaza 19.9 33.6 92

Sources: IDS 2003; MOH 2005 (Ronda 4)

Preliminary Results

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

linear programming

Selected characteristics of study mothers -1

Age (y) [SD] 25.8 [6.0]

# Children < 5 yrs 2.0 [1.0]

Electricity in home* 26.3%

Refrigerator in home* 17.5%

Unprotected water source 45.3%

Cooks with wood or charcoal (fire) 95.6%

Reads Portuguese** 37.0%

Baby’s father contributes to HH budget 78.4%

Median per capita daily food expenditure [IQR]

5000 MT [2500-7500]

$0.20/day

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

Home garden 17.5%

Cultivated field 57.7%

Owns chickens 40.9%

Owns goats 19.0%

Owns oxen 9.5%

Owns other animals (e.g. ducks) 22.6%

Report current food shortage 42.2%

Report receiving food assistance 21.2%

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)

Results of food frequency % infants regularly consuming different food groups by

age (reported > 4 times/week)

0

20

40

60

80

100

6-8 m 9-12 m >12 m

%

Meat/poultry Fish Eggs

Milk Starches Legumes

Vegetables Fruits Oils/Sugar

% 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

0

20

40

60

80

100

Manica Sofala Gaza

%

Meat/poultry Fish Eggs

Milk Starches Legumes

Vegetables Fruits Oils/Sugar

Infant diets are somewhat varied across provinces with Gaza diets having the lowest variety of foods regularly consumed due to drought/food crisis

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

Age Median IQR

< 6 mo 1 [0-2]

6-8 mo 3 [2-5]

9-12 mo 4 [2-6]

Preliminary results from linear programming

6-8 months9-11 months

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

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

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, breast milk, cow’s milk

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

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

countries• 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

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

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

Collaborators

Elizabeth Glaser Pediatric AIDS FoundationCathrien Alons, Victorino Chavane, Ellen Warming, Cathy Wilfert

Health Alliance InternationalWendy Johnson, Florencia Floriano, James Pfieffer

ANSALourdes Fidalgo

Academy for Educational Development

Ellen Piwoz

Ministry of HealthSonia Kahn, Atalia Macombe

Save the ChildrenKatarina Regina, Ronnie Lovich

WHOAndré Briend

OtherMartha Piedrasanta