Describe infant and young child feeding practices.

Breastfeeding

• The WHO/UNICEF recommendations, which should be stated exactly:
• 1. Initiate breastfeeding within one hour of birth
• 2. Exclusive breastfeeding for the first six months — nothing else, not even water
• 3. Introduce adequate, appropriate complementary foods at six months
• 4. Continue breastfeeding to two years and beyond
• The advantages of breastfeeding should be grouped, since a list is easily forgotten:
• For the infant — nutritional: ideal composition, changing with the age of the baby and even during a single feed
• The foremilk is watery and quenches thirst; the hindmilk is fat-rich and satisfies hunger — which is why the baby must be allowed to finish one breast before being offered the other, and why switching breasts too early produces a hungry, poorly growing, windy baby
• Human milk protein is chiefly whey, forming soft, easily digested curds, unlike the casein-dominant cow milk
• It contains lactose for brain development, essential fatty acids, and iron in a form that is poorly concentrated but highly absorbed
• Immunological — secretory IgA, lactoferrin, lysozyme, macrophages, leucocytes, bifidus factor and oligosaccharides, protecting against diarrhoea, respiratory infection and otitis media
• Colostrum, the yellow milk of the first few days, is especially rich in antibody and vitamin A, and is frequently discarded as "dirty" or "stale" in Indian practice — so counselling to give colostrum is a specific and worthwhile intervention
• Other infant benefits — lower risk of allergy, asthma and eczema; lower later obesity and diabetes; better cognitive outcomes; reduced necrotising enterocolitis in preterm infants; and lower sudden infant death
• For the mother — uterine involution and reduced postpartum haemorrhage through oxytocin release; lactational amenorrhoea, giving natural child spacing; reduced risk of breast and ovarian cancer; return to pre-pregnancy weight; and emotional bonding
• For the family and society — free, always available at the right temperature, requires no fuel, water or equipment, and carries NO risk of contamination
• That last point IS decisive where water is unsafe — artificial feeding in a household without clean water and fuel is dangerous, and the risk of death from diarrhoea in a non-breastfed infant is many times higher
• The lactational amenorrhoea method is a legitimate contraceptive only if three conditions all hold — the infant is under 6 months; breastfeeding is fully or nearly exclusive, day and night; and menstruation has not returned. It is then about 98% effective, but failure of any one condition requires another method

Complementary Feeding, Problems and Protection

• Complementary feeding begins at six months, and the timing is a genuine balance — too early displaces breast milk, introduces infection and allergens, and increases diarrhoea; too late fails to meet growing energy and nutrient needs, causing growth faltering, and misses the window for accepting new tastes and textures
• Growth faltering in Indian children typically begins around 6 months, which points directly at inadequate complementary feeding rather than at breastfeeding
• The principles of good complementary feeding — continue breastfeeding; increase frequency, amount, thickness and variety progressively with age; use energy-dense foods; ensure hygienic preparation and feeding; and practise responsive feeding
• The commonest error is that food is too dilute and too infrequent — a watery gruel fills a small stomach without providing energy
• Energy density is increased by adding oil or ghee, and by using germinated (malted) flour, which reduces viscosity without adding water and is a genuinely useful practical technique
• Foods should be enriched by adding pulses, milk, egg, oil, sugar, groundnut and green leafy vegetables to the family staple
• Responsive feeding means feeding slowly and patiently, encouraging but not forcing, minimising distractions, and feeding the child directly rather than leaving the plate
• By 1 year the child should be eating the family diet, suitably modified
• Common breastfeeding problems and their management:
• "not enough milk" is the commonest complaint and is usually a matter of confidence and technique rather than true insufficiency
• The reliable signs of adequacy are weight gain and passing urine at least six times a day, and demonstrating these to the mother is usually the whole treatment
• Sore and cracked nipples are almost always caused by poor attachment — so the remedy is to correct the attachment, not to rest the breast
• The four signs of good attachment are worth knowing — the baby’s mouth wide open; the chin touching the breast; the lower lip turned out; and more areola visible above than below the mouth
• Engorgement — treated by frequent feeding, warm compress before and cold after, and expression; mastitis — treated by continuing to feed from the affected breast, together with antibiotics and analgesia, since stopping causes stasis and abscess
• Inverted nipples, managed with a syringe technique or by expressing; and feeding of low birth weight infants by expressed breast milk, spoon or paladai feeding, and kangaroo mother care
• The obstacles in India — delayed initiation; discarding colostrum; prelacteal feeds of honey, water, jaggery or animal milk; early water in the belief that the baby is thirsty; the high caesarean rate delaying first contact; maternal employment without maternity leave or creche; and commercial promotion of infant formula
• The protective measures — the infant milk substitutes act (IMS Act, 1992 amended 2003), which prohibits all advertising and promotion of infant milk substitutes, feeding bottles and infant foods, bans free samples and gifts to mothers and health workers, and requires prescribed warnings on labels
• The baby friendly hospital initiative with its ten steps to successful breastfeeding; MAA (Mothers Absolute Affection); maternity benefits and paid leave; and counselling by ASHAs and Anganwadi workers at home visits
• Let the baby finish one breast first, since foremilk quenches thirst and hindmilk satisfies hunger
• Switching breasts early makes a hungry baby, and the mother concludes she has insufficient milk
• Counsel specifically to give colostrum, which is still widely discarded as dirty or stale
• Cracked nipples mean poor attachment, so correct the attachment rather than resting the breast
• Continue feeding from a breast with mastitis, since stopping causes stasis and abscess
• Weight gain and six wet nappies confirm adequacy, and demonstrating them is usually the whole treatment
• Growth faltering begins around six months, which points at complementary feeding rather than at breastfeeding
• Complementary food is usually too dilute and infrequent, so a watery gruel fills the stomach without giving energy
• Add oil or ghee to raise energy density, and use malted flour to reduce viscosity without adding water
• Responsive feeding means encouraging, not forcing, and feeding the child directly rather than leaving the plate
• Four signs mark good attachment — wide mouth, chin touching, lower lip turned out and more areola above
• Artificial feeding is dangerous without clean water, and multiplies the risk of death from diarrhoea
• Lactational amenorrhoea needs all three conditions — under six months, near-exclusive feeding and no menses
• Prelacteal feeds of honey and water are common in India and should be specifically discouraged
• The IMS Act bans all promotion of infant milk substitutes, bottles and infant foods, including free samples
• Human milk protein is chiefly whey, forming soft digestible curds unlike casein-dominant cow milk
• Breast milk iron is low but well absorbed, which is why the concentration alone misleads
• Kangaroo mother care suits low birth weight infants, alongside expressed milk given by spoon or paladai
• Breastfeeding reduces maternal cancer risk, of breast and ovary, which is worth mentioning when counselling
• By one year the child eats the family diet, suitably modified, which is a simple message for mothers
• Caesarean delivery delays first contact, and needs specific attention if early initiation is to be achieved
• The Baby Friendly Initiative has ten steps, and hospital practice is what determines initiation more than counselling does