Policy Gradually Able to Eat Normal Family Food (Around One Year)

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■ Policy gradually able to eat normal family food (around one year). The latter period is also referred to as weaning. The term weaning does not denote termination of breastfeeding. Appropriate feeding is crucial for IAP POLICY ON the healthy growth and development of INFANT FEEDING the infant. However, lack of confidence and widespread ignorance and miscon- ceptions frequently result in improper management of infant feeding. The pro- minent areas of concern include discar- ding or minimal feeding of colostrum or delayed initiation of breastfeeding by Background nearly 80% of mothers, non exclusive breastfeeding by 85-90% in the first four Appropriate nutritional practices months of life, unnecessary utilization play a pivotal role in determining opti- of commercial infant milk foods and mal health and development of infants. animal milks, early termination of Concerned by the lack of uniform breastfeeding and premature or delayed guidelines for appropriate infant feed- introduction of semi-solids which may ing practices in the Indian context, the be contaminated, low in caloric density IAP Subspecialty Chapter on Nutrition and fed less frequently. These inept conducted a Workshop to define a feeding practices, directly or indirectly, Policy on Infant Feeding (Appendix). contribute substantially to infectious Subsequently, these recommendations illnesses, malnutrition and mortality in were endorsed as the official Indian infants. Academy of Pediatrics Policy on Infant Feeding and as National Guidelines on The Policy on Infant Feeding aims at Infant Feeding by the Food and Nutri- promotion of suitable feeding practices tion Board, Department of Women and to advance child care, growth and Child Development, Ministry of Human development, reduce the prevalence of Resource Development, Government of protein energy malnutrition (PEM), India. Vitamin A deficiency and infectious diseases, particularly diarrhea, and Contents of the IAP Policy on Infant improve survival. The Policy focuses on Feeding the strategy of educating and motiva- Ideal infant feeding comprises exclu- ting the families to adopt proper infant sive breastfeeding for 4 to 6 months fol- feeding methods through the existing lowed by sequential addition of semi- health infrastructure and other develop- solid and solid foods to complement ment programmes for women and (not replace) breastmilk till the child is children. POLICY

A. Appropriate Infant Feeding management of breastfeeding. In the Practices last trimester of pregnancy, breast and nipples should be examined and rele- I. Breastfeeding vant advise given. Expectant mothers 1. Advantages of Breastfeeding should be counseled to eat an extra helping of the family food with some It is a proven scientific fact that all green vegetables. Additional rest of half commercial infant milk foods and ani- to one hour and wherever possible, mal milks are inferior to breastmilk: switching to relatively lighter work (i) Maternal milk is nutritious food for during the last trimester should be infants which is readily available, propagated. simple to feed, hygienic, develops emo- tional bonding and prevents allergic dis- 3. Starting Breastfeeds orders; (ii) Breastfeeding protects against several infections including Practically all mothers, including diarrhea and respiratory infections, and those with mild to moderate chronic saves lives. An exclusively breastfed malnutrition, can successfully breast- infant is about 14 times less likely to die feed. Soon after delivery, the mother from diarrhea, 3 to 4 times less likely to should be allowed to keep the newborn die from respiratory disease and 2 to 3 with her (rooming-in). After a normal times less likely to die from other infec- delivery, babies should receive the first tions than a non breastfed infant; breastfeed as soon as possible and pre- (iii) Breastmilk is much more economi- ferably within one hour of birth. During cal than artificial milk or powdered milk this period and later, the normal new- food—the average cost of feeding a 6 born should not be given any other fluid month old infant for one month on or food like honey, "ghutti", animal or infant formula may even be equal to the powdered milk, tea, water, glucose average monthly per capita income; water, etc. since these are potentially (iv) "Exclusive" breastfeeding exerts harmful. strong contraceptive effect in the first It is essential that the baby gets the 4-6 months post partum; (v) Maternal first breastmilk called colostrum which benefits include earlier termination of is thicker and yellower than later milk post partum bleeding and protective and comes only in small amounts in the effect against breast and ovarian cancer. first few days. Colostrum is all the food 2. Preparation for Breastfeeding During and fluid needed at this time—no Pregnancy supplements are necessary, not even water. The expectant mothers, particularly primiparas and those experiencing diffi- The mother, especially with the first culties with lactation management ear- birth, may need help in the proper posi- lier, should be motivated and prepared tioning for breastfeeding. Breastfeeds to exclusively breastfeed. This should be should be given as often as the baby achieved by educating, through a per- desires and each feed should continue sonal approach, about the benefits and for as long as the infant wants to suckle.

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After a cesarean section, breastfeed- 6.2. Common Illnesses in the Infant ing should be started as soon as possible Breastmilk is the most easily diges- and preferably within z4 hours of deli- tible food for an ill baby. Feeding very. The mother will need help to put human milk is actually beneficial in the baby to the breast for a day or two. common infantile ailments including 4. Exclusive Breastfeeding diarrhea and acute respiratory infections. Breastfeeding must, therefore, be During the first few months and as ensured during such illnesses. The child far as possible, till the age of 4-6 months, may suckle less vigorously or for a "exclusive" breastfeeding should be prac- shorter time and should receive the ticed; young infants do not require any feeds at more frequent intervals. How- additional food or water or any other ever, breastfeeding and for that matter, fluid such as tea, herbal water, glucose any type of feeding should not be water, fruit drinks, etc. Breastmilk alone attempted in critically ill infants. is adequate to meet the hydration re- quirements even under extremely hot 6.3. Illness in Mother and dry summer conditions of the coun- Most common maternal illnesses do try. not require discontinuation of breast- 5. Diet of Lactating Mother feeding. Breastfeeding is recommended even with mastitis, breast abscess and A lactating woman should be other infectious illnesses including uri- advised to eat an extra helping of the nary tract infection, tuberculosis, family food and regular consumption of human immunodeficiency virus (AIDS), green leafy vegetables. There is no need hepatitis and other viruses. However, to avoid any specific foods; however, physically incapacitating systemic ill- use of excessive caffeine, tobacco, and nesses may prevent or necessitate dis- alcohol, etc. should be discouraged. continuation of breastfeeding. Psychosis 6. Important Special Situations is a contraindication for breastfeeding on account of abnormal maternal beha- 6.1. Low Birth Weight Infants vior. In such situations, wherever Mother's milk is the best food for the feasible, the breasts should be emptied low birth weight babies. The borderline frequently to maintain lactation. term and growth retarded low birth 6.4. Drug Intake in Mother weight babies can suckle fairly well at the breast and should be fed on Drug therapy should be avoided in demand. However/ low birth weight lactating mothers and when necessary, a and other high risk infants who cannot safer alternative should be prescribed. suckle, should be given expressed Drug intake should preferably be timed breastmilk in preference to formula during or immediately after breastfee- feeds by appropriate techniques such as ding. Majority of the commonly used clean cup and spoon, tubes, "paladai", preparations are compatible with safe etc. The child should be put directly to breastfeeding. Only a few drugs necessi- the breast as soon as possible. tate discontinuation of breastfeeding

157 POLICY like anti cancer and anti thyroid frequency of feeding and low calorie therapy, radioactive preparations, ergot, density of the additional foods. gold salts, lithium, etc. 2. Timing of Introduction of Semi-solids 6.5. Breastfeeding Substitues Semi-solid foods- to supplement If a mother can not for some reason breastmilk should be introduced bet- exclusively breastfeed her young infant ween four to six months of age and pre- (below 4 to 6 months age), for example a ferably at six months in poor communi- working mother, her expressed milk ties. Within this age range, the indi- should be given to the baby in prefe- vidual decision should be guided by the rence to other animal or formula milks. growth performance and physiological maturation of the infant. To minimize Rarely, if it is unavoidable—at least any interference with the normal course partially—to give non human milk in the of breastfeeding, semi-solid foods first 4 to 6 months of life, undiluted milk should preferably be given between normally consumed by the family breastfeeds. should be utilized and commercial infant milk foods should be strongly 3. Continuation of Breastfeeding discouraged. In infants, part of exces- At first breastmilk is the baby's main sive fat in buffalo's milk should be food and the weaning diet is extra. removed by separating the cream from Later, even when more semi-solid food milk after boiling and cooling to room is added, breastmilk still continues to temperature. Young infants who are remain an important component of the solely on cow's or buffalo's milk need infant's diet. Breastfeeding should con- additional plain water supplementation. tinue for as long as feasible and prefer- A clean cup and spoon should be used ably well into the second year of life. instead of a bottle with nipple. 4. Feeding Guidelines II. Addition of Semi-solid and Solid 4.1. Formulate Additional Foods from the Foods Usual Family Diet 1. Importance of Appropriate Addition The weaning (complementary) diet After 4-6 months of age many should be cooked from the usual family mothers do not have enough milk to foods in a thickened but mashed (soft- form the sole source of nutrition for the ened) form and variety attempted. Use infant and addition of other foods is, of commercial weaning foods should be therefore, essential to prevent growth avoided, as far as possible. faltering. Delayed introduction of addi- Family pot feeding—giving the family tional foods in an exclusively breastfed foods in a mashed form, without or be- infant results in malnutrition. Improper fore adding hot spices or extra salt, and introduction of these foods is fraught providing something extra like oil/fat with dangers of: (i) diarrhea due to and green vegetables is best since it is infection from unhygienic preparation, economical, saves time and the infant and (ii) malnutrition related to inad- grows up accustomed to the traditional equate calorie intake due to low foods.

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4.2. Enhancing Nutritive Value millet, etc.) enriched with oil/fat and/or animal milk (if possible) or mashed The nutritive value of these foods fruits like banana (or other seasonal should be enhanced by enrichment of fruits like papaya, mango, etc.). One or the staple cereal with pulses (for pro- two teaspoonfuls are enough to start teins), oil/fat/sugar (for Increasing calo- with and the quantity and frequency rie density) and green vegetables (for should be gradually increased. The baby Vitamins especially A, B and C, and at the end of this phase should be con- iron). Advantage should be derived suming about 50 to 60 g of food (half a from the usual diet pattern of a mixture cup) per day. of cereals and pulses (idli, dosa, pongal, khichri, missi roti, etc.) by addition of 4.3.2. Six to Nine Months some oil/fat/sugar and green vegetables. Dilution of weaning diet and From 6-9 months of age the baby use of watery gruel and lentil or vege- should be used to feeding from the table water should be strongly discoura- family pot (mashed rice with dal, ged. Use of animal milk, milk products, khichri, a little chappati softened in dal fruits, eggs, fish or meat, if culturally or milk, dahi, mashed vegetables, fruits, acceptable and affordable, can be etc. enriched with some oil/fat and encouraged. The bulk of the weaning green vegetables). They need four to food can be reduced by malting of five weaning meals a day, in addition to grains/cereals. regular breastfeeding. 4.3. Frequency, Amount and Consistency of 4.3.3. Nine to Twelve Months Feeding—Broad Age Related Guidelines Near about 9 months, babies can Infants vary grossly in the amount start chewing on soft food. The food at that they require and eat. In general, this time does not need to be mashed therefore, mothers should be advised to but, if required, can be chopped or prepare and offer a mixed nourishing pounded. A variety of household foods diet based on the usual family foods and should be given four to five times a day leave it to the baby to take as much as is and the quantity gradually increased. desired. The child's general activity and By about one year, young children growth as judged by the family and the should be eating foods cooked for the health worker and confirmed by weigh- family but at least four to five times a ing as often as possible depending on day. A child of one to two years needs the facilities, is good evidence of about half the food that the mother eats. adequate food intake. However, the following broad feeding guidelines can be 5. Preparation and Storage of Weaning offered. Foods 4.3.1. Four to Six Months Careful hygienic preparation and storage of weaning foods is crucial to Between the age of 4-6 months one prevent contamination. The hands can start with cereal based porridge should be thoroughly washed with soap (suji, wheat flour, ground rice, ragi, and water before preparation and

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feeding, and the cooking place and tely before they are to be eaten. If food utensils must be clean. The foods should has been kept for over two hours, it is be preferably fresh, cooked or boiled desirable to reheat it thoroughly until it well and if feasible, prepared immedia- boils before consumption.

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6. Feeding During and After Common adoption of appropriate infant feeding Illnesses methods. The medical and paramedical personnel of the Departments of Pediat- Feeding should continue during rics and Obstetrics and Gynecology common ailments like diarrhea, respira- should perform the central role for insti- tory infections, etc. unless the medical tutional deliveries. In addition, services condition of the child contradicts it. Re- of other community level workers and striction or dilution of food should be involvement of formal and non formal discouraged. Despite anorexia, the in- education, media and voluntary organi- fant can be coaxed to eat small quanti- zations is recommended to be utilized ties but more frequently (every 2-3 for the effective implementation of the hours). After illness, the child should be Policy. provided more than the usual diet to regain the weight lost. In this context, due attention should be given to "The Infant Milk Substitutes, B. Operational Guidelines for Feeding Bottles and Infant Foods (Regu- Promotion of Proper Infant Feeding lation of Production, Supply and Distri- I. Through Child Survival and Safe bution) Act of Parliament, 1992 and it's Motherhood (CSSM) and Other contents adhered to. Developmental Programmes for II. Institutional Promotion of Women and Children Appropriate Breastfeeding The Policy should form an integral In order to actively protect, promote part of the Child Survival and Safe and support breastfeeding, every faci- Motherhood Programme (CSSM) of pri- lity providing maternity services and mary health care (Table I). In addition, it care for newborn infants should practice should be effectively operationalized the following ten steps: through the managers and functionaries of the ongoing Programmes primarily 1. Have a written breastfeeding related to Women and Child Develop- policy that is routinely communi- ment such as Integrated Child Develop- cated to all health care staff. ment Services (ICDS), Urban Basic Ser- 2. Train all health care staff in skills vices for the Poor (UBSP), Development necessary to implement this of Women and Children in Rural Areas policy. (DWCRA) and Programmes implemen- ted by the Non-Government Organiza- 3. Inform all pregnant women about tions (NGO's). The managers and func- the benefits and management of tionaires of these Programmes should breastfeeding. be practically oriented to the correct 4. Help mothers initiate breast- principles of infant feeding and this sub- feeding within an hour of birth. ject should form an essential part of the nursing and undergraduate medical 5. Show mothers how to breastfeed, curriculum. All health care providers and how to maintain lactation should actively educate and motivate even if they should be separated the mothers and other relatives for from their infants.

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6. Give newborn infants no food or Acknowledgements drink other than breastmilk, unless medically indicated. The Workshop was supported by the 7. Practice rooming in—allow moth- United Nations Children's Fund, India ers and infants to remain to- Country Office. The draft Policy on gether -24 hours a day. Infant Feeding had been prepared after intensive interaction with Dr. Olivia 8. Encourage breastfeeding on Yambi and Dr. Sheila Vir of the Child demand. Development and Nutrition Section of 9. Give no artificial teats or pacifiers the United Nations Children's Fund, (also called dummies or soothers) India Country Office. to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer Compiled by H.P.S. Sachdev, mothers to them on discharge Convener. from the hospital or clinic.

APPENDIX-Members of the Workshop on Policy on Infant Feeding The following members of the Indian Academy of Pediatrics (IAP) comprised the "Expert Group on Policy on Infant Feeding" under the auspices of the IAP Sub-Speciality Chapter on Nutrition. They contributed to the finalization of the document by either attending the "Workshop on Policy on Infant Feeding" in Hotel Ashok, New Delhi on February 9,1994 at 4 pm, or in absentia Ct) by communicating their comments on the draft document circulated a month prior to the meeting. The recommendations of this Expert Group were subsequently endorsed as the official IAP Policy on Infant Feeding at the IAP Executive Board meeting in July, 1994.

1. Dr. K.N. Agarwal*, 4. Dr. S.K. Bhargava*, Director, Consultant Pediatrician Institute of Medical Sciences, and former Convener, Varanasi. Steering Committee IAP, 0-7, Gulmohar Park, 2. Dr. Y.K. Amdekar*, New Delhi 110049. President Elect, Indian Academy of Pediatrics, 5. Dr. P. Bhaskaram, Vora House, Deputy Director, Bhimani Street, National Institute of Nutrition, Matunga, Indian Council of Medical Research, Bombay 400019. Jamai-OsmaniaP.O. 3. Dr. R.K. Anand*, Hyderabad 500 007, A.P. Honorary Pediatrician, 6. Dr. Uday Bodhanka*, Jaslok Hospital and Research Centre, President, 55, Kavi Apartments, Indian Academy of Pediatrics, Wodi, Near Post Office, Dhantoli, Bombay 400 018. Nagpur 440 012, Maharashtra.

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7. Dr. S.N. Chaudhuri*, 14. Dr.HemantA.Joshi*, Director, Convener, Consumer Protection IAP, Child in Need Institute, Children and General Joshi Hospital, Post Box 16742, Calcutta A Wing, 1st Floor, Vartak Road, 700 027, W.B. Opposite Railway Station, Virar(W)401303, Maharashtra. 8. Dr. B.C. Chhaparwal*, Member Governing Body 15. Dr. Nirmala Kesaree, (Central Zone), IAP Director, Sub-Speciality Chapter on Nutrition Bapuji Child Health Institute and Professor of Pediatrics, and Research Centre, Shrinath Dwar, 14-A, Ratlam Kothi, 191/1,3rd Main, Indore 452 001, Madhya Pradesh. P 5 Extension, 9. Dr. Panna Choudhury, Davangere577002, Senior Pediatrician, Karnataka. Department of Pediatrics, 16. Dr. M.R. Lokeshwar*, Maulana Azad Medical College and General Secretary, Associated LokNayak Jaiprakash Indian Academy of Pediatrics, Narayan Hospital, 19/54, Welfare Mansion, Sion, New Delhi 110 002. Bombay 400 002. , 10. Dr. Armida Fernanadez, Professor of Pediatrics (Neonatology), 17. Dr.SushilMadan*, L.T.M. Medical College and Hospital, Former Chairperson, IAP Sion, Bombay 400 022. Sub-Speciality Chapter on Nutrition, Consultant Pediatrician, 11. Dr. Shanti Ghosh, 401/2, Block "G", New Former Consultant, World Health Alipore, Calcutta 700 053, Organization W.B. (Maternal and Child Health) and Former Head, Department of Pediatrics 18. Dr.G.P.Mathur*, Safdarjung Hospital, New Delhi, Former Professor of Pediatrics, 5, Sri Aurobindo Marg, R-2 Medical College Campus, New Delhi 110 016. Kanpur208002,U.P. 12. Dr. Suraj Gupte, 19. Dr. Meenakshi N. Mehta, Member Governing Body Member Governing Body (North Zone), (West Zone), IAP Sub-Speciality Chapter on IAP Sub-Speciality Chapter on Nutrition, Nutrition, Professor of Pediatrics, Professor and Head, 60, Lower Gumat, Jammu 181001. Department of Pediatrics, L.T.M. Medical College and Hospital, 13. Dr.S.Jayam*, Sion, Bombay 400 022. President, National Neonatology Forum and 20. Dr. Saroj Mehta*, Additional Professor of Pediatrics and Chairperson, IAP Sub-Speciality Neonatology, 31, First Main Road, Chapter on Gastroenterology, Kamarajar Nagar West, Madras 600 1159, Sector 15-C, 041. Chandigarh 160 015.

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21. Dr. Indira Narayanan, 26. Dr. Bharat Shantilal Shah, Senior Consultant, Treasurer, LAP Sub-Speciality Department of Pediatrics, Chapter on Nutrition, Moolchand Hospital, 119 Tapovan Society, S.M. L-10, Kailash Colony, Road, Ambavadi, New Delhi 110 048. Ahmedabad 380 015, Gujarat. 22. Dr. R.K.Puri, 27. Dr. NiranjanShendurnikar, Editor, Indian Pediatrics and Assistant Professor, Director Professor and Head, Department of Pediatrics, Department of Pediatrics, Maulana Medical College, Azad Medical College, New Delhi Baroda, Gujarat. 110 002. 28. Dr. S. Thirupuram, 23. Dr. S. Ramji, President, Delhi Branch of Secretary, Indian Academy of Pediatrics and National Neonatology Forum and Professor, Department of Pediatrics, Associate Professor, Department of Maulana Azad Medical College, Pediatrics, Maulana Azad Medical New Delhi 110 002. College, New Delhi 110 002. 29. Dr.ShashiN.Vani, 24. Dr.VinodiniReddy, Chairperson, IAP Sub-Speciality Director, Chapter on Nutrition and National Institute of Nutrition, Professor and Head, Jamai Osmania P.O. Department of Pediatrics, Hyderabad 500 007, A.P. Medical College Ahmedabad, No. 1, Professor's Quaters, 25. Dr. H.P.S. Sachdev (Convener), Civil Hospital, Secretary, LAP Sub-Speciality Ahmedabad 380 016, Gujarat. Chapter on Nutrition and Associate Professor and Chief, Division of Clinical 30. Dr.B.N.S.Walia*, Epidemiology, Department of Director and Professor of Pediatrics, Pediatrics, Maulana Azad Medical Postgraduate Institute of Medical College, New Delhi 110 002. Education and Research Chandigarh 160 012.

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