MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
MCFC Egyptian Journal of Breastfeeding
Volume (7) Jan-May, 2013
Theme of current issue Nutrition and Non-Communicable Diseases Issued by the Mother & Child Friendly Care Association
1
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
MCFC-Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan-May, 2013 Theme: Breastfeeding and non-communicable disease Dr. Ghada Anwar, Cairo University Issued by Mother and Child Friendly Dr. Nagiuba Lotfi, Alexandria University. Care Association Dr. Nahed Fahmy, Cairo University Alexandria (Registration no. 2538-2010) Dr. Mohamed Naguib Massoud, Alexandria Editor in Chief University Dr. Azza MA Abul-Fadl, Dr. Omima Abu Shady, Cairo University, Benha University, President of MCFC President of EMWA Guest Editor International Advisory Board (in Prof. Edward Kaplan, USA alphabetical order) Dr. Anne Batterjee, KSA Editors for this edition Dr.Arun Gupta, MD, FIAP, IBFAN, India Dr. Maissa Shawky, Prof. Cairo University Ms. Deborah Lacroix, Canada Dr. Hager Yasin, IBCLC Dr Djamil Lebane, Algiers Dr. Aziz Kolielat, Lebanon Dr. Elizabeth Horman, Germany Dr.Arun Gupta, MD, FIAP, IBFAN, India Dr. Felicity Savage, UK. Egyptian Editorial Board (in alphabetical Dr. Karin Cadwell, USA order) Dr. Karl Bergmann, Germany Dr. Ahmed Amr Abbassy, Prof. Alexandria Dr. Khalid Iqbal, UAE University Dr. Lilas Tomeh, Syria Dr. Alaa Elinguebawy, Consultant Surgeon Ms. Wendy AlRubaei, IBFAN, UAE Dr . Ahmed ElSad Younes, Police Hospital Ms. Mariam Nooh, Bahrain Dr. Ahmed Gamal Abu ElAzayem, Dr. Mona AlSomaie, MoH, Kuwait Psychiatrist Dr. Renate Bergmann, Germany Dr. Amina Lotfi, WHO consultant IYCF Ms. Suman Bhatia, India Dr. Eman Abdel Raouf, Cairo University Ms. Zehra Baykal, Turkey Dr. Esmat Mansour, Consultant UNICEF Guidelines for authors of original research studies: Authorship. Authors should give their full names and the name and address of their institutions. Tables and Figures should be numbered consecutively (e.g. Table 1, Fig. 1) and should not exceed a total of 4. Abstracts should not exceed 250 words, in English at the beginning and is translated into Arabic, at the end of the article. The body of the text should be structured as Background, Methods, Findings and Discussion, typed in a double spaced word document (font 12 Times New Roman), not exceeding 12 pages (size A4). The journal does not accept any papers or work funded by infant milk formula companies or code violators. Ethical considerations for work on mothers and babies should be clearly described. References should not exceed 30. They should be in American Psychological Association (APA) style used for citing in social sciences articles. Then they are sorted alphabetically and numbered for reference in the text. For more information on references please refer to http://owl.english.purdue.edu/. Correspondence information Mother and Child Friendly Care Association 10, Dameitta Street – Bolkly – Alexandria – Apt,143, Email: [email protected]
2
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Table of Content
Introduction: A special tribute to landmarks in health care 4
Section I: Editorial articles 5 I.1. The global burden of non-communicable disease 5 I.2. Malnutrition, infant feeding and non-communicable disease 9 I.3. Complementary feeding and non-communicable disease 13 1.4. Micronutrients and non-communicable diseases 15 I.5. Prevention and control of non-communicable diseases 21
Section II : Original Research Studies
An intervention to reduce exposure of neonates to environmental tobacco smoke by exclusive breastfeeding: Abed NT, Waked N, Abul- Fadl A, ElHady H, Mostafa ME. 29 Delay of early prefeeding responses in cesarean delivery interferes with outcome of breast-feeding at hospital discharge : Khairy M, 41 ElRefaey D, ElSayed MA, Abul-Fadl A.
Challenges facing the “Updated Baby Friendly Hospital” Program in a
Maternity Hospital in Alexandria: Fawzi A, Kadry H, Abd Rabo S, 53 Abul-Fadl A.
Determinants of vitamin D status of exclusively breastfed babies in the first six months of life: Abdel Haie OM., Elfiky UA, Yousif AA, Ibrahim DEF. 67 Nutritional status and co-morbidites influence the evolving disease pattern of rheumatic heart in Egypt: Abul-Fadl AMA, Ghamrawy A. Sherif H. 81 Miscellaneous 95 Role of International Board Certified Lactation Consultants (IBCLCs) in Making Hospitals Baby Friendly: Abul-Fadl A, Tawfik E, Abdel Mohsen N. 95 Arabic Section 97 ______
2
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Introduction: A Special Tribute to Landmarks in Health Care ______This special issue is dedicated to the around her were key to her success and growing burden of non-communicable leadership. Her attachment and dedication diseases particularly in our region and to caring for her own mother in her around the world. terminal illness succumbed her into her We dedicate this issue to all our dear own fate, a fate that deprived us of a professors and scientific workers who professor whom we consider as an icon in have had made astounding and her field and whose unique and unforgettable contributions to making a inspirational work will influence future difference in the field of medical science, generations to come. research and management and whose A memorable and unforgettable icon who beliefs have made influenced our was close to our hearts in Benha Faculty understanding of the holistic approach to of medicine is the departure of our former medical care. dean of faculty and head of obstetric and In this notion, we would like to remember gynecology department: the late Professor Naila Amer, professor of Professor Mohsen Khairy, yet another quality management in the High Institute special icon who pioneered as a surgeon of Public Health of Alexandria in updated technologies of IVF, University, who dedicated her life to the laparoscopy and laser therapies. He had a teaching and continuous education and passion for excellence in medical care research in quality in health care through his holistic approach to management. She was the founder of the management of educational institutions. collaborative WHO Regional training His charismatic social relationship made centre for the Eastern Mediterranean him stand up in every situation. Adding Region and North Africa located in the beauty to bring life to a health care High Institute of Public Health, where facility was his motto in life. This was hundreds of candidates from the entire evident during his term as a dean when he region were trained and went back to introduced many innovative structural their health facilities, districts and and administrative changes in the hospital countries to implement the concepts of and faculty that resulted in its recognition total quality management. In the later among other faculties in the country and years of her life she introduced this in the region as a credible teaching and training through online courses medical care institution. disseminating it to thousands and making May God bestow them both with His it a culture for improving health care mercy and forgiveness and rest them in service delivery. She was an inspiring, the blissful Heavens of eternity. dedicated and sincere pioneer in her field whose expression of love to all those The EJBF Chief Editor Azza Abul-Fadl
4
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Section I: Editorial articles I.1 The Burden of Non-communicable Disease and Health Care Service Delivery The World Health Organization (WHO) transition with increases in pre-obesity estimates deaths from cardiovascular and obesity particularly in urban areas (2) disease, cancer, chronic respiratory disease and diabetes which were 63 per cent of global mortality in 2008 to increase: by 2030, to become the greatest killer in all low and middle income countries (LMIC). Hence non- communicable diseases (NCDs) are becoming a global health and developmental emergency, as they cause premature deaths, exacerbate poverty and threaten national economies. NCDs are also becoming an increased burden for Non-communicable or chronic diseases health care systems and represent both a account for over 50% of annual deaths financial and managerial challenge. and 60% of disease burden in the Eastern Mediterranean Region (EMR). Moreover the shift in the trends in Deaths attributed to cardiovascular mortality rates from communicable disease (CVD) in the EMR range from diseases towards NCDs is starting from 49% in Oman to 13% in Somalia. Cancer late childhood, both in developed and deaths are reported to range from 20% in developing countries. This will increase Qatar to 3% in Somalia and Afghanistan. the lifespan cost of medical care and There are very high rates of diabetes in resulting in rise in health care the Region; 6 countries out of the 10 expenditures around the world. The most globally with the highest prevalence of striking is the rise in mortality rates diabetes are in the Region. Prevalence attributable to heart disease, cancer and rates of over 18% are reported in some stroke, which represent diseases that countries. require costly health care interventions The prevalence of noncommunicable (see figure). In a study that examined disease risk factors is high in most death from 187 countries deaths from countries of the Region. Data indicate non-communicable diseases rose by just that more than one quarter of the adult under 8 million between 1990 and 2010, population has high blood pressure. A accounting for two of every three deaths high prevalence of hypercholesterolemia (34·5 million) worldwide by 2010 (1). In was noted with a range of between 14% Bangladesh there is an epidemiological and 52% among adults aged 15–65 years. transition with large reductions in The Region has the highest rates of mortality due to acute, infectious, and physical inactivity, among other regions. parasitic diseases and increases in non- About 50% of women and more than a communicable, degenerative, and chronic third of men are insufficiently active. diseases over the last 20 years. There is Tobacco consumption, prevalence of also evidence of an adult nutritional 5
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
smoking among adult men ranges influenced by poverty, ignorance, poor between 7% and 57% (3). hygience and healthy lifestyles, In Libya death from NCD accounts for environmental pollution and illiteracy (5). 78% of all death with CVD as the leading Developed countries have enjoyed cause at 43%. In Morocco it accounts for substantial falls in cardiovascular disease 76% with CVD as the lead cause in 40%. (CVD) mortality. However, low and While in Algeria and Tunisia, although middle income countries are drowning in NCDs form 63% and 72% still a rising tide of CVD and other non- communicable, maternal and nutritional communicable diseases. Current and diseases form 29% and 22% compared to future trends in CVD mortality will CVD in 28% and 29% respectively (3). therefore require increasing attention in In Egypt NCD accounts for 82% of all the 21st century. The success of clinical deaths mostly due to CVD in 39% cardiology in providing evidence-based followed by cancer in 11%. Deaths are cost-effective treatments should be more prevalent in males 198/1000 celebrated. However, the growing compared to 172/1000 in females. This is understanding of CVD mortality trends the highest prevalence among males in highlights the crucial role of tobacco the region, ranging from 60/1000 in smoke, diet and sedentary life as key Morocco to 20/1000 in Libya for men and drivers (7). In South East Asia region of less for women (3). the total deaths (14.5 million), NCDs in Egypt range from hypertension cardiovascular diseases account for 25%, in around 35% for both males and chronic respiratory diseases 9.6%, cancer females and diabetes in 6.2% of males 7.8% and diabetes 2.1%. Also their focus and 6.9% of females. Behavioural risk is to address few preventable risk factors, factors include smoking, with a all of which are highly prevalent in the prevalence of 35% among males. region as tobacco use, unhealthy diet, Metabolic risk factors include overweight lack of physical activity and harmful use being high in Egypt with a prevalence of of alcohol (7). 75% of overweight among females and 60% among males. Obesity is 21.4% NCD rates are not simply the byproduct among males and 44.5% among females. of an aging population: more than 50% of Raised cholesterol is 33.3% among males its global burden strikes those under the and 43.7% among females (3). age of 70. Beyond the immediate suffering and death represented by these In South Africa child mortality has numbers, NCDs take a toll on benefited from progress in addressing development, in rising health care costs HIV. However, more attention to and lost productivity. An authoritative postnatal feeding support is needed. study has estimated that the cumulative Many risk factors for non-communicable costs of Non communicable diseases will diseases have increased substantially be at least $47 trillion (8). during the past two decades as a result of poor infant and adult feeding practices, Nationwide scaling with pro-active public including infant milk formula feeding, health approaches are increasingly consumption of salt and alcohol (4). The recognized as being powerful, rapid, relative burden due to non communicable equitable and cost-saving. But the diseases (NCD) is on the rise worldwide resistance to this is substantial and with gender disparities and comorbidities advocacy and awareness are needed to 6
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
sensitize policy makers (6). Prevention and with large number of beds and staff to control of NCDs requires a shift: from care for these patients to ambulatory care vertical programs that address each NCD practices and hospices care settings that separately to integrated horizontal provide multifaceted care needs of programs, and from using costly chronically ill patients and their families. biomedical approaches to cost effective The importance of using a multi-faceted public health approaches characterized by and comprehensive program to promote access to all, social and health care sustainable system change has been equity. Political commitment and demonstrated to be effective in facing the intersectoral collaboration are needed to challenge of NCD rising turf. Key effectively and efficiently reverse the elements of focus on the use of rapid rising trend in the global burden and cost appropriate assessment and treatment at of NCDs (8). primary care level, strengthening the Health systems, statistics and surveillance referral system, interministerial and programs must respond to the intersectoral liaison, rehabilitation, social demographic, economic and inclusion, promotion and advocacy to epidemiological transitions that define the mobilize community engagement. current disease burden and risk profile. Mental health problems are of There is a critical need to improve public considerable importance and influence health intelligence by building the magnitude and effectiveness of health epidemiological capacity in the region care services that are provided to and scaling interventions at national NCDs(10). Evidence shows that change level(8). The control of NCDs must be can be achieved by improvements in the comprehensive and multi-sectoral, mobilization of additional public integrating health promotion, prevention resources; availability of health and treatment strategies, and involving infrastructure and drugs; service the community as well as the health utilization; effective coverage; and sector. Such multi-faceted approaches financial protection. Future challenges are require well-functioning health systems. needed for additional public funding to In the majority of LMICs, however, extend access to costly interventions for health systems are fragile and will need to non-communicable diseases not yet be adapted to address NCDs covered by the new insurance scheme, appropriately. Several policy issues will and to improve the technical quality of also need to be addressed, including care and the responsiveness of the health financing of NCD programs and the system (11). Moreover the medical care broadening of concepts of health and responsibilities for health. A priority team must include multiple specialties issue is that health systems need to be and varying levels of care in order to restructured to respond to NCD. This will cover the diverse health care needs of require a change in mindset and practices such patients. Among children this will in programming for health, as well as also require protecting their normal growth and developmental needs by substantial financial resources(9). providing services that are integrated in This will require a paradigm shift in the within a milieu that does not interfere management of delivery of health care with their normal development and that with the downsizing of large hospitals can promote it.
7
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
References Asia region: burden, strategies and 1- Lozano R, Naghavi M, Foreman K, Lim opportunities. Natl Med J India. S, Shibuya K, Aboyans V et al. (2012) 24(5):280-7. Global and regional mortality from 235 8- Thomas B, Gostin LO. (2013) Tackling causes of death for 20 age groups in 1990 the Global NCD Crisis: Innovations in and 2010: a systematic analysis for the Law and Governance. Symposium on Global Burden of Disease Study 2010. global health and the law in Journal of Lancet. 15;380(9859):2095-128. law, medicine & ethics, spring pp 16:26. 2- Mascie-Taylor N.(2012) Is Bangladesh 9- Dhillon PK, Jeemon P, Arora NK, Mathur going through an epidemiological and P, Maskey M, Sukirna RD, Prabhakaran nutritional transition? Coll Antropol. D.(2012) Status of epidemiology in the 36(4):1155-9. WHO South-East Asia region: burden of 3- World Health Organization - NCD disease, determinants of health and Country Profiles , 2011 epidemiological research, workforce and 4- Mayosi BM, Lawn JE, van Niekerk A, training capacity. Int J Epidemiol. Bradshaw D, Abdool Karim SS, Coovadia 41(3):847-60. HM. (2012) Health in South Africa: 10- Robinson HM, Hort K.(2012) Non- changes and challenges since 2009. Lancet communicable diseases and health 8;380(9858):2029-43. systems reform in low-and-middle-income 5- Stevens A, Schmidt MI, Duncan BB. countries. Pac Health Dialog. 18(1):179- (2012) Gender inequalities in non 90. communicable disease mortality in Brazil. 11- Kiima D, Jenkins (2010) Mental health Cien Saude Colet. 17(10):2627-34. policy in Kenya -an integrated approach to 6- O'Flaherty M, Buchan I, Capewell S. scaling up equitable care for poor (2013) Contributions of treatment and populations. Int J Ment Health Syst. lifestyle to declining CVD mortality: why 28;4:19. have CVD mortality rates declined so 12- Frenk J, Gómez-Dantés O, Knaul much since the 1960s? Heart.99(3):159- FM.(2011) The democratization of health 62. in Mexico: financial innovations for 7- Narain JP, Garg R, Fric A. (2011) Non- universal coverage. Bull World Health communicable diseases in the South-East Organ. 87(7):542-8.
This quote is from Mother Theresa. “People are often unreasonable, illogical, and self-centered, forgive them anyway. If you are kind, People may accuse you of selfish, ulterior motives; be kind anyway. If you are successful, you will win some false friends and some true enemies; succeed anyway. If you are honest and frank, people may cheat you; be honest and frank anyway. What you spend years building, someone can destroy overnight; build anyway. If you find serenity and happiness, there may be jealousy; be happy anyway. The good you do today, people will often forget tomorrow; do good anyway. Give the world the best you have, and it may never be enough; give the world the best you’ve got anyway. You see, in the final analysis, it is between you and Allah; it was never you and them anyway.”
8
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
I.2 Malnutrition, Infant Feeding Practices and Predicted Risk of Non-communicable Disease: An agenda for action ______It is estimated that 171 million children region of Africa stunting has not changed under 5 are stunted in growth (2010). (40.2 percent in 1990, 39.3 percent Malnutrition is a direct consequence of Globally exclusive breastfeeding rates up poor early infant feeding practices. to 6 months of age have increased from 14 percent in the 1990s to 35 percent in Malnutrition impacts mortality in the the 2008 with marked improvements in following ways: the South East Asia region to 43 percent, Childhood malnutrition is the and within the 30s in the other regions underlying cause of death in an except for Europe were it is lowest in estimated 35percent of all deaths Europe to 14 percent. among children under the age of five Within regions some countries have years. shown considerable success stories in More than two million children die reducing stunting such as Turkey and each year as a result of undernutrition Bangaledash (3 and 3.9 percent before the age of five years. respectively) and Saudi Arabia and China Maternal and child undernutrition (7.3 and 6.percent respectively). The accounts for 11percent of the global common characteristic shared by these burden of disease. countries are the improved rate of infant Childhood malnutrition (PCM) feeding practices particularly in countries impacts the health and well being of as Turkey reaching 40 percent and Sri children in the following ways: Lanka 76 percent, the latter is the highest PCM increases the prevalence of short achieved exclusive breastfeeding rates adult stature among countries reported in 2012 by the PCM reduces lean body mass World Health Organization. While the PCM impairs cognition and decline in the exclusive breastfeeding educational performance rates in countries as Indonesia and Iran PCM lowers the productivity and decreased by 50 percent from 63 percent adult wages to 32 percent in the former and 44 % to PCM increases the risk of chronic 23 % in the latter, while in Tunisia it diseases decreased to 6 percent from 47 percent, PCM predisposes women to stunting which is an alarming decline (UNICEF and risk of delivering lower birth Global data base, 2009). weight babies. Overweight prevalence has increased Trends in malnutrition over the past from 4 percent to 8.5 percent in Africa decades: and from 3.2 percent to 4.9 percent in Stunting prevalence has considerably Asia but has remained unchanged in reduced over the past two decades (from Latin America (6.8 percent in 1990 and 1990 to 2010) in Asia from 48.6 percent 6.9 percent in 2010). Hence the emerging to 27.6 percent and Latin America from problem of obesity which is the 23.7 to 13.5 percent. However in the underlying risk for many non-
9
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
communicable diseases (NCDs) regulate energy intake, energy particularly cardiovascular disease which expenditure, and cellular chemistry. head the list in NCDs. Breasmilk contains leptin and gherlin that Infant feeding and obesity play a role in satiety, promoting self Decades of epidemiological research regulation of intake in breastfed infants. have established that breastfeeding is These protective effects may promote associated with a modest reduction in risk slower growth and lower body fat levels of later overweight and obesity. The in breastfed infants, which reduce risk of pattern of early feeding practices overweight and obesity later in life (2). influence later child health outcomes There is evidence from systemic review including overweight and feeding habits conducted for 70 studies that suggests through programming'. Systematic that initial breastfeeding may reduce the reviews suggest that breastfeeding is prevalence of obesity throughout life. associated with a modest reduction in the Breastfeeding was associated with a risk of later overweight and obesity. The slightly lower mean BMI than was underlying mechanisms behind this formula feeding (-0.04; 95% CI: -0.05, - association may be related to behavioural 0.02). The mean difference in BMIs and hormonal mechanisms. appeared larger in 15 small studies of Artificial-feeding stimulates a higher <1000 subjects (-0.19; 95% CI: -0.31, - postnatal growth velocity with the 0.08) and smaller in larger studies of adiposity rebound occurring earlier in >or=1000 subjects (-0.03; 95% CI: -0.05, those children who have greater fatness -0.02). These studies did not examine later, whereas breastfeeding has been exclusive breastfeeding practices for six shown to promote slower growth. The months, nor did they consider continued adverse long-term effects of early growth breastfeeding for two years and other acceleration emerge as later overweight confounding factors as early use of bottle and obesity. The higher protein content of and mixed feeding(3). artificial baby milk compared to the A systematic review of published lower protein content in breastmilk is observational studies relating initial responsible for the increased growth rate infant feeding status to blood cholesterol and adiposity during the influential period concentrations in adulthood (ie, aged >16 of infancy of formula-fed infants. y from 17 studies showed that Breastfeeding, on the other hand, has a breastfeeding is associated with lower protective effect on child overweight and blood cholesterol concentrations in obesity by inducing lower plasma insulin adulthood (4). levels, thereby decreasing fat storage and Breastfeeding and cardiovascular risk preventing excessive early adipocyte (1) A total of 9377 persons born during 1 development . week in 1958 in England, Scotland, and Another underlying mechanism for the Wales were followed-up periodically protective effects of breastfeeding is by from birth into adulthood. Infant feeding encouraging the infant's emerging was recorded as breastfed partially or capabilities of self-regulation of intake; wholly for <1 month, or breastfed for >1 reducing problematic feeding behaviors month. Breastfeeding for >1 month was on the part of caregivers that interfere associated with reduced waist with the infant's self-regulation of intake; circumference, waist/hip ratio, von and providing bioactive factors that Willebrand factor, and lower odds of
10
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
obesity compared with formula feeding suggest that breastfeeding is associated after adjustment for other with a modest reduction in CVS diseases cardiorespiratory risk factors (5). Hence by reducing the risk of later overweight the protective effect of breastfeeding for and obesity(7). cardiorespiratory risk factors in adult life Moreover a cost effective analysis may not be major for short periods of showed that if 90% of United States breastfeeding especially when not families could comply with medical exclusive. However many other studies recommendations to breastfeed that distiniguished breastfeeding from exclusively for 6 months, the country bottle-fed ones reported that would save $13 billion per year and breastfeeding is associated with increased prevent an excess 911 deaths related to mean total cholesterol and low density the above mentioned conditions (10). lipoprotein (LDL) levels in infancy but Meeting the challenge of poor lower levels in adulthood/adult life; infant feeding practices suggesting that breastfeeding may have The Sixty three World Health Assembly long-term benefits for cardiovascular (WHA 63.23) in May 2010 announced (6) (CVS) health . the revised Global Infant and young child Moreover, during late infancy many feeding strategy infants are exposed to high protein intake, 1. Reduction of childhood stunting by a which is more than three times as high as target of 40% reduction of the global the physiological need. This increases the number of children under five who are risk of developing obesity and thereby stunted. NCDs later in life. This effect was 2. Reduction of anaemia in women of supported by a recent intervention study reproductive age by a target of 50% with infant formulas with two levels of reduction of anaemia in non pregnant protein, showing that a higher protein women of reproductive age. intake during the first year of life 3. Reduction of low birth weight by a resulted in a higher body mass index target of 50% reduction of low birth (BMI) at age 2 years(6,7). weight. Nutrition interventions for NCDs focus 4. No increase in childhood overweight on prevention by improving early by a target of 0% increase in the infant feeding practices: But Why? prevalence of overweight in children The relationship between early infant under five. feeding practices and development of 5. Increase exclusive breastfeeding rates chronic disease states is well established. in the first six months of life by a Several studies have shown that exclusive target of 50% increase of exclusive breastfeeding can prevent a number of breastfeeding rates in the first six NCDs including diabetes mellitus, celiac, months of life. leukemia, lymphoma, Chrons disease, The Comprehensive action plan on allergic diseases, coronary and maternal, infant and young child hypertensive heart disease. The nutrition mechanism by which early nutrition in ACTION 1: To create a supportive infancy may influence later child health environment for the implementation of outcomes may be through 'programming' comprehensive food and nutrition of the body systems especially the policies. immune system (8,9). Systematic reviews 11
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
ACTION 2: To include all required 2- Bartok CJ, Ventura AK. (2009) effective health interventions with an Mechanisms underlying the association impact on nutrition in plans for scaling between breastfeeding and obesity. Int J up. Pediatr Obes.4(4):196-204. 3- Owen CG, Martin RM, Whincup PH, ACTION 3: To stimulate the Davey-Smith G, Gillman MW, Cook DG. implementation of non health (2005) The effect of breastfeeding on interventions that impact nutrition. mean body mass index throughout life: a ACTION 4: To provide adequate human quantitative review of published and and financial resources for the unpublished observational evidence. Am J implementation of health interventions Clin Nutr. 82(6):1298-307. with an impact on nutrition. 4- Owen CG, Whincup PH, Kaye SJ, Martin ACTION 5: To monitor and evaluate the RM, Davey Smith G, Cook DG (2008) implementation of policies and programs. Does initial breastfeeding lead to lower blood cholesterol in adult life? A Infant and Young Child Feeding quantitative review of the evidence. Am J (IYCF) Clin Nutr. 88(2):305-14. Protection, promotion and support of 5- Rudnicka AR, Owen CG, Strachan DP. appropriate IYCF (2007) The effect of breastfeeding on – Exclusive breast feeding for 6 months cardiorespiratory risk factors in adult life. – Complementary feeding (need 6- Michaelsen KF, Larnkjær A, Mølgaard strengthening and support for use of local C.(2012) Amount and quality of dietary foods, food fortification, micronutrient proteins during the first two years of life supplementation) in relation to NCD risk in adulthood.Nutr Metab Cardiovasc Dis. 22(10):781-6. – Feeding of IYC in difficult 7- Oddy WH.(2012) Infant feeding and circumstances (HIV, malnutrition, obesity risk in the child.Breastfeed Rev. emergencies, LBW) 20(2):7-12. • Health services 8- Frolkis A, Dieleman LA, Barkema H, – Baby Friendly Hospital Initiative Panaccione R, Ghosh S, Fedorak RN, – Pre-service education and in-service Madsen K, Kaplan GG .(2013) training Environment and the inflammatory bowel • Maternity protection diseases.Can J Gastroenterol. 27(3):e18- • Code of marketing of breastmilk 24. 9- Viner RM, Hindmarsh PC, Taylor B, Cole substitutes TJ.(2008) Childhood body mass index • Monitoring and evaluation (BMI), breastfeeding and risk of Type 1 A study to evaluate prenatal exposure to diabetes: findings from a longitudinal breastfeeding information from various national birth cohort. Diabet Med. sources showed that maternal knowledge 25(9):1056-61. of benefits, family and clinician support, 10- Bartick M, Reinhold A.(2010) The burden and peer practices influence breastfeeding of suboptimal breastfeeding in the United outcomes in early infancy (11). States: a pediatric cost analysis.Pediatrics. Hence encouragement of breastfeeding 125(5):e1048-56. 11- Kornides M, Kitsantas P. (2013) needs to be a priority among health care Evaluation of breastfeeding promotion, providers to improve the health of support, and knowledge of benefits on mothers and infants. breastfeeding outcomes.J Child Health References Care. Feb 25. [Epub ahead of print] 1- Oddy WH. (2012) Infant feeding and obesity risk in the child. Breastfeed Rev. 20(2):7-12. 12
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
1.3. Complementary Feeding and Non- Communicable Diseases ______Background of infants in several of the countries. Suboptimal feeding patterns during the Thus, enhancing infant/young child first two years of life are key health can significantly reduce determinants of malnutrition in children morbidities and mortalities, as well as and constitute an important predictor of adult-onset diseases, ultimately health in later years. Early-childhood decreasing the region's overall burden of nutritional factors, stunting, and obesity disease (1,2) . have been highlighted as prominent core Early protein intake and later NCD underlying factors of Non-Communicable The contribution of protein intake in early Disease (NCD) development whereas the life to later NCD development has been improvement of complementary feeding the object of several studies; however practices has been cited as one of the future research should specifically target most effective preventive strategies for the effects of early protein intake on (a) reducing malnutrition and adult NCDs. how protein intake influences body This is because early dietary and feeding composition, (b) how different body patterns may set in place growth patterns composition in infancy contributes to and/or metabolic pathways that promote later NCDs, (c) whether there is an age risk factors for later NCDs. Although 'window' when high protein intake is studies so far have limited validity for particularly associated with later evaluating the impact of early feeding on overweight and obesity, (d) what levels of later disease, yet available evidence is protein intake may protect against later building and is inducing worldwide overweight/obesity, (e) what level of cow responses for action. milk intake in the first years of life minimises risk-inducing growth whilst Complementary feeding in the MENA meeting recommended calcium intakes. region: practices and challenges. During late infancy many infants have a In the MENA region NCD prevalence protein intake, which is more than three shows very high rates and the limited times as high as the physiological need. available studies show that current Several observational studies have shown practices fall behind global an association between a high-protein recommendations. Common to all intake (>15 energy %) early in life and an countries of this region are practices of increased risk of developing obesity and mixed breast and bottle-feeding as early thereby NCDs later in life. This effect as the first month, as well as the was supported by a recent intervention premature introduction of complementary study with infant formulas with two foods. Early introduction of non-milk levels of protein, showing that a higher fluids, such as sweetened water and protein intake during the first year of life herbal teas, has been described as a resulted in a higher body mass index common practice in the region and the (BMI) at age 2 years. premature introduction of complementary It is also plausible that an important foods has been reported in as high as 80% reason for the slower growth in breast-fed
13
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
infants is the lower content of protein in regions, different countries and different breastmilk, but other qualities of socio-economic environments. breastmilk could also play a role. How could complementary feeding A high intake of protein, especially dairy patterns affect the susceptibility to protein, stimulates the growth factors NCD later in life? insulin-like growth factor (IGF-I) and Potential mechanisms by which insulin, and it has been suggested that the complementary feeding may influence lower risk of NCDs in breast-fed infants the risk of developing non-communicable is mediated through a regulation of IGF-I. diseases (NCDs) are numerous including A low quality of protein, as in cereal- diet composition as well as patterns of based diets with no animal foods as often feeding have the potential to influence the seen in low-income countries, may early development of obesity, which in contribute to undernutrition, which can turn predicts later obesity and NCD risk. also result in an increased risk of NCDs Specific dietary exposures during the later in life. In conclusion, there is some period of complementary feeding also evidence that a high protein intake during have the potential to program future the complementary feeding period is disease risk through pathways that are associated with increased risk of NCDs independent of adiposity. These factors and that avoidance of a high protein all require consideration when making intake could reduce the risk of obesity. In recommendations for optimal low-income countries, emphasis should complementary feeding practices aimed be on providing sufficient amounts of at prevention of future NCDs (4). high-quality protein to improve survival, References growth and development (3). 1- Nasreddine L, Zeidan MN, Naja F, Hwalla Moreover the role of the quality of fat N. (2012) Complementary feeding in the and carbohydrate intakes at early ages MENA region: practices and challenges. should be better investigated. There is a Nutr Metab Cardiovasc Dis. 2012 dearth of data from many communities Oct;22(10):793-8. 2- Poskitt EM, Breda J. (2012) about the foods introduced as Complementary feeding and non complementary feeds, the ages at which communicable diseases: current they are introduced and why mothers use knowledge and future research needs. Nutr these foods. Definitely more information Metab Cardiovasc Dis. 2012 is needed on how and to what extent Oct;22(10):819-22. mothers' behaviour is influenced by 3- Michaelsen KF, Larnkjær A, Mølgaard C. media, advertising and other commercial Amount and quality of dietary proteins pressures and why formula fed infants are during the first two years of life in relation started on other foods much earlier than to NCD risk in adulthood. 4- Adair LS. (2012) How could breast fed infants. Standardized protocols complementary feeding patterns affect the are needed to develop more data on susceptibility to NCD later in life? Nutr complementary feeding in different Metab Cardiovasc Dis. 2012 Oct;22(10):765-9
14
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
1.4. Micronutrients and Noncomunicable Diseases ______Vitamin D and Cardiovascular deficiency and insufficiency have Disease been defined as a 25-hydroxyvitamin The increasing worldwide D <20 ng/ml and 21-29 ng/ml displacement from the natural outdoor respectively. For every 100 IU of environment of human beings to an vitamin D ingested the blood level of indoor sedentary lifestyle, along with 25-hydroxyvitamin D, the measure the recommendation to avoid any vitamin D status, increases by 1 direct sun exposure because of the ng/ml. It is estimated that children risk of skin cancer, and environmental need at least 400-1000 IU of vitamin pollution that impede the ultraviolet D a day while teenagers and adults rays from penetrating the heavy need at least 2000 IU of vitamin D a polluted atmosphere of urban cities, day to satisfy their body's vitamin D are some factors linked to the global requirement (3). pandemic of vitamin D insufficiency. Vitamin D deficiency and heart Although its deficiency is linked with disease bone disease, several recent Accumulating evidence suggests that investigations have highlighted a vitamin D deficiency is associated potential link between vitamin D with cardiovascular disease, and that deficiency and increased risk of heart vitamin D therapy may have disease. Observational studies suggest significant mortality and morbidity cardioprotective benefits related to benefits in the treatment of congestive supplementation, but randomized heart failure (CHF). However, the trials remain to be conducted (1). It is potential protective role of vitamin D estimated that 1 billion people on the heart; and its mechanism of worldwide are vitamin D deficient or action as a hormone in this organ, is insufficient. Correcting and not fully understood (3). preventing this deficiency could have The role of vitamin D in chronic an enormous impact on reducing heart failure health costs worldwide (2). Vitamin D is an emerging agent with Epidemiologic evidence and tremendous potential and may prospective studies have linked represent a novel target for therapy in vitamin D deficiency to the increased CHF. The mechanism(s) involved in risk of many chronic diseases the pathophysiology and the role of including autoimmune diseases, Vitamin D measurement and cardiovascular disease, deadly supplementation in patients with CHF cancers, type II diabetes and is high on the agenda of investigators infectious diseases. Vitamin D worldwide. Despite advanced medical
15
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
and device–based therapies, CHF intracellular mechanisms that manage remains a major medical problem, calcium metabolism and energy associated with significant morbidity production. These functions can be and mortality. Vitamin D deficiency altered once vitamin D deficiency is prevalent in CHF and is associated develops (8). with poor outcomes. Vitamin D has been shown to A clear relationship has been influence cardiac contractility and established between Vitamin D myocardial calcium homeostasis. 25- deficiency and increased mortality hydroxyvitamin D [25(OH)D] levels and morbidity in CHF. Vitamin D has were assessed in 3299 Caucasian direct effect on heart cells and patients who were routinely referred indirect effect on the risk factors of to coronary angiography at baseline the disease. Vitamin D insufficiency (1997-2000). The main outcome was seems to predispose to hypertension, cross-sectional associations of left ventricular hypertrophy, CHF, 25(OH) D levels with measures of and chronic vascular inflammation (4). heart failure and Cox proportional In elderly CHF patients, vitamin D hazard ratios for deaths due to CHF deficiency was highly prevalent and and coronary disease (SCD) often severe. An echocardiography according to vitamin D status. study showed an association between 25(OH) D was negatively correlated vitamin D deficiency and left with N-terminal pro-B-type ventricular dilation (5). natriuretic peptide and was inversely Four major potential mechanisms associated with higher NYHA classes may be important to explain the direct and impaired left ventricular function. effects of vitamin D against CHF: During a median follow-up time of These include: effect on myocardial 7.7 yr, 116 patients died due to heart contractile function, the regulation of failure and 188 due to SCD. After natriuretic hormone secretion, the adjustment for CVD risk factors, the effect on extracellular matrix hazard ratios (with 95%confidence remodelling and the regulation of intervals) for death due to CHF and inflammation cytokines. It has been for SCD were 2.84 (1.20-6.74) and demonstrated that vitamin D has a 5.05 (2.13-11.97), respectively, when high impact on CHF main risk factors comparing patients with severe as hypertension, renin-angiotensin vitamin D deficiency [25(OH)D <25 system malfunction and nmol/liter)] with persons in the atherosclerosis. In spite of the robust optimal range [25(OH)D > or =75 preclinical data only few clinical nmol/liter]. They concluded that low observations prove the positive effect levels of 25(OH) D and 1,25- of vitamin D on CHF(4,6,7). dihydroxyvitamin D are associated Vitamin D, indeed, stimulates the with myocardial dysfunction, deaths synthesis of various contractile due to CHF, and SCD. Interventional proteins and activates crucial trials are warranted to elucidate
16
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
whether vitamin D supplementation is The steroid hormone vitamin D useful for treatment and/or prevention regulates gene expression of many of myocardial diseases (9). This was genes that play a prominent role in also verified by other workers who the progression of heart failure, such reported that Vitamin D deficiency as cytokines and hormones. was highly prevalent in CHF patients Specifically, vitamin D is a negative and is a significant predictor of regulator of the hormone renin, the reduced survival and that vitamin D pivotal hormone of the renin- supplementation is associated with angiotensin system. improved outcomes (10). Mechanistic insights were gained by Hypovitaminosis D has been studying mice deficient for the observed to be highly prevalent in the vitamin D receptor, which develop CHF community with rates varying hypertension and adverse cardiac from approximately 80% to 95%. remodeling mediated via the renin- Higher rates of deficiency have been angiotensin system. Furthermore, linked to winter months, in patients vitamin D receptor is expressed in the with protracted de-compensated CHF, heart and regulated under pro- darker skin pigmentation, and higher hypertrophic stimuli and vitamin D as NYHA classes. In fact, some data receptor has been associated with the suggest vitamin D deficiency may expression of other hypertrophic even be an independent predictor of genes such as natriuretic peptides. mortality in patients with CHF Epidemiological data and mechanistic Studies have shown that the studies have provided strong support association between vitamin D for a potentially cardioprotective deficiency and CHF often manifests effect of vitamin D. It remains in the structural components of unclear if vitamin D supplementation cardiac myocytes and/or through is beneficial in preventing heart alterations of the neurohormonal failure or if it could be a therapeutic cascade. In addition, vitamin D may addendum in the treatment of heart also act rapidly through intracellular failure(12). nongenomic receptors that alter Vitamin D and Hypertension cardiac contractility. Blacks have significantly higher rates Although prospective vitamin D of hypertension than whites, and supplementation trials showed mixed lower circulating levels of 25– results, experimental models, have hydroxyvitamin D. Systolic and shown that correction of deficiency diastolic pressure and 25– was associated with reductions in hydroxyvitamin D measured ventricular hypertrophy. Still in periodically showed a difference in humans echocardiographic systolic pressure of +1.7 mm Hg at 3 dimensions did not change months for those receiving placebo, - significantly (11). 0.66 mm Hg for 1000 U/d, -3.4 mm Hg for 2000 U/d, and -4.0 mm Hg for
17
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
4000 U/d of cholecalciferol i.e. for effect of vitamin D therapy on blood each 1–ng/mL increase in plasma 25– pressure and CVD risk (14). hydroxyvitamin D, there was a Low serum calcidiol has been significant 0.2–mm Hg reduction in associated with multiple co– systolic pressure (P=0.02). Within an morbidities and mortality. It was unselected population of blacks, 3 concluded that Vitamin D in the 20– months of oral vitamin D3 36 ng/ml range may be associated supplementation significantly, yet with the lowest risk for mortality and modestly, lowered systolic pressure. morbidity. The hazard ratio below Future trials of vitamin D and above this range increases supplementation on blood pressure significantly. During the 54–month are needed to confirm these study period, 422,822 Clalit Health promising results, particularly among Services members were tested for blacks, a population for whom calcidiol of which 12,280 died of any vitamin D deficiency may play a cause (905 with acute coronary more specific mechanistic role in the syndrome) and 3,933 were diagnosed pathogenesis of hypertension (13). with acute coronary syndrome. The antihypertensive effects of Compared to those with 20–36 ng/ml, vitamin D include suppression of the adjusted hazard ratios among renin and parathyroid hormone levels those with levels of < 10, 10–20 and > and renoprotective, anti-inflammatory 36 ng/ml were 1.88 [CI: 1.80–1.96], 1.25 and vasculoprotective properties. Low [CI:1.21–1.30] and 1.13 [CI:1.04–1.22], (16) 25-hydroxyvitamin D levels, which (P < 0.05) respectively . are used to classify the vitamin D However, if vitamin D is important in status, are an independent risk factor the etiology of atherosclerosis, it is for incident arterial hypertension. unclear at what stage(s) in the Meta-analyses of randomized atherosclerotic disease process controlled trials showed that vitamin vitamin D may exert its effects. D supplementation reduces systolic Large-scale, well-conducted, placebo blood pressure by 2-6 mm Hg(14). controlled clinical trials testing the Moreover vitamin D deficiency has efficacy of vitamin D been associated with cardiovascular supplementation in delaying, slowing, disease (CVD) risk factors such as or reverting the atherosclerotic hypertension and diabetes mellitus, disease process have not yet been with markers of subclinical conducted. Until the results of these atherosclerosis such as intima-media studies are available, we believe it is thickness and coronary calcification premature to recommend vitamin D as well as with cardiovascular events as a therapeutic option in (17, 18, 19) such as myocardial infarction and atherosclerosis . stroke as well as CHF (15). However, Vitamin D and renal disease further studies are needed before Vitamin D3 is made in the skin, drawing a final conclusion on the modified in the liver to form
18
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
25(OH)D, and then further Summary and conclusions hydroxylated in the kidney to form Vitamin D deficiency is a highly the active hormone, 1,25- prevalent condition, present in dihydroxyvitamin D3 (calcitriol). approximately 30% to 50% of the Calcitriol binds to and activates the general population. A growing body vitamin D receptor (VDR), a nuclear of data suggests that low 25- receptor, to regulate numerous hydroxyvitamin D levels may downstream signaling pathways in adversely affect cardiovascular different cells and tissues. Emerging health. Vitamin D deficiency evidence suggests that VDR plays an activates the renin-angiotensin- important role in modulating aldosterone system and can cardiovascular, immunological, predispose to hypertension and left metabolic and other functions. Data ventricular hypertrophy. Additionally, from preclinical, epidemiological and vitamin D deficiency causes an clinical studies have shown that increase in parathyroid hormone, deficiency in VDR activation is which increases insulin resistance and associated with an increased risk for is associated with diabetes, CVD. hypertension, inflammation, and Results from interventional trials increased CVD. using either nutritional vitamin D or Epidemiologic studies have VDR agonists (VDRAs) support the associated low 25-hydroxyvitamin D idea that VDR activation is beneficial levels with coronary risk factors and for improving the underlying factors adverse cardiovascular outcomes. of CVD such as hypertension, disease Vitamin D supplementation is simple, vascular endothelial dysfunction, safe, and inexpensive. Large atherosclerosis, vascular calcification, randomized controlled trials are cardiac hypertrophy and progressive needed to firmly establish the renal dysfunction. Furthermore, a relevance of vitamin D status to majority of chronic kidney disease cardiovascular health. In the (CKD) patients die of CVD and meanwhile, monitoring serum 25- VDRA therapy is associated with a hydroxyvitamin D levels and survival benefit in both pre-dialysis correction of vitamin D deficiency is and dialysis CKD patients (20). indicated for optimization of Epidemiologic studies suggested that musculoskeletal and general health patients who had chronic kidney (22). disease and were treated with References activated vitamin D had a survival 1- Chan WK, Redelmeier DA. (2012) Simpson's paradox and the association between vitamin D advantage when compared with those deficiency and increased heart disease. Am J who did not receive treatment with Cardiol. 1;110 (1):143-4. (21) 2- Holick MF (2011) Vitamin D: evolutionary, these agents . Although potentially physiological and health perspectives. Curr useful yet at present VDRAs are not Drug Targets. 12(1):4-18. indicated for the treatment of CVD. 3- Lee W, Kang PM (2010) Vitamin D deficiency and cardiovascular disease: Is there a role for 19
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
vitamin D therapy in heart failure? Curr Opin 12- Meems LM, van der Harst P, van Gilst WH, de Investig Drugs. 11(3):309-14. Boer RA. (2011) Vitamin D biology in heart 4- Mascitelli L, Goldstein MR, Pezzetta F. (2010) failure: molecular mechanisms and systematic [Vitamin D deficiency and cardiovascular review.Curr Drug Targets. 12(1):29-41. diseases]. Recenti Prog Med. 101(5):202-11. 13- Forman JP, Scott JB, Ng K, Drake BF, Suarez 5- Ameri P, Ronco D, Casu M, Denegri A, Bovio EG, Hayden DL, Bennett GG, et al. (2013) M, Menoni S, et al. (2010) High prevalence of Effect of vitamin D supplementation on blood vitamin D deficiency and its association with pressure in blacks. Hypertension. 61:779. left ventricular dilation: an echocardiography 14- Pilz S, Tomaschitz A. (2010) Role of vitamin D study in elderly patients with chronic heart in arterial hypertension.Expert Rev Cardiovasc failure.Nutr Metab Cardiovasc Dis. 20(9):633- Ther. 8(11):1599-608. 40. 15- Gouni-Berthold I, Krone W, Berthold HK. 6- Pourdjabbar A, Dwivedi G, Haddad H.(2013) (2009) Vitamin D and cardiovascular disease. The role of vitamin D in chronic heart Curr Vasc Pharmacol. 7(3):414-22 failure.Curr Opin Cardiol. 2013 Jan;28(2):216- 16- Dror Y, Giveon SM, Hoshen M, Feldhamer I, 22. Balicer RD, Feldman BS. (2013) Vitamin D 7- Szabó B, Merkely B, Takács I.(2009) [The role Levels for Preventing Acute Coronary of vitamin D in the development of cardiac Syndrome and Mortality: Evidence of a Non- failure]. Orv Hetil. 2009 Jul 26;150(30):1397- Linear Association Journal of Clinical 402. Endocrinology and Metabolism. 98 (5): 2160. 8- Cioffi G, Gatti D, Adami S.(2010) [Vitamin D 17- Brewer LC, Michos ED, Reis JP.(2011) deficiency, left ventricular dysfunction and Vitamin D in atherosclerosis, vascular disease, heart failure].G Ital Cardiol (Rome). 2010 and endothelial function.Curr Drug Targets. Sep;11(9):645-53. 12(1):54-60. 9- Pilz S, März W, Wellnitz B, Seelhorst U, 18- Patel R, Rizvi AA. (2011) Vitamin D Fahrleitner-Pammer A, Dimai HP, Boehm BO, deficiency in patients with congestive heart Dobnig H.(2008) Association of vitamin D failure: mechanisms, manifestations, and deficiency with heart failure and sudden cardiac management.South Med J. 104(5):325-30. death in a large cross-sectional study of patients 19- McGreevy C, Williams D.(2011) New insights referred for coronary angiography.J Clin about vitamin D and cardiovascular disease: a Endocrinol Metab. 93(10):3927-35. narrative review.Ann Intern Med. 10- Gotsman I, Shauer A, Zwas DR, Hellman Y, 20;155(12):820-6. Keren A, Lotan C, Admon D (2012) Vitamin D 20- Wu-Wong JR. (2011) Vitamin D therapy in deficiency is a predictor of reduced survival in cardiac hypertrophy and heart failure.Curr patients with heart failure; vitamin D Pharm Des.;17(18):1794-807. supplementation improves outcome.Eur J Heart 21- Artaza JN, Mehrotra R, Norris KC.(2009) Fail. 14(4):357-66 Vitamin D and the cardiovascular system.Clin J 11- Agarwal M, Phan A, Willix R Jr, Barber M, Am Soc Nephrol.;4(9):1515-22. Schwarz ER. (2011) Is vitamin D deficiency 22- Lee JH, O'Keefe JH, Bell D, Hensrud DD, associated with heart failure? A review of Holick MF.(2008) Vitamin D deficiency an current evidence.J Cardiovasc Pharmacol Ther. important, common, and easily treatable 16(3-4):354-63. cardiovascular risk factor?J Am Coll Cardiol. 9;52(24):1949-56.
20
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
I.5. THE PREVENTION AND CONTROL OF NON- COMMUNICABLE DISEASES
Excerpts from the WHO/WHA Action plan for the prevention and control of non-communicable disease 2013 -2020 (WHO Executive board EB132/7, 132nd session 11 January 2013)
INTRODUCTION The toll of morbidity, disability and The global burden and threat of non- premature mortality due to non- communicable diseases constitute a communicable diseases can be greatly major challenge for development in the reduced if preventive and curative twenty-first century, one that interventions already available are undermines social and economic implemented effectively. Most development throughout the world and premature deaths from non- threatens the achievement of communicable diseases are preventable internationally agreed development by influencing public policies in sectors goals in low-income and middle- other than health, rather than by making income countries. An estimated 36 changes in health policy alone. million deaths, or 63% of the 57 million Governments have recognized that deaths that occurred globally in 2008, quick gains against the epidemic of were due to non-communicable non-communicable diseases can be diseases, comprising mainly made through modest investments in cardiovascular diseases (48%), cancers interventions. Although there is no (21%), chronic respiratory diseases blueprint and one size does not fit all, (12%) and diabetes (3.5%).1 In 2008, widespread implementation of these around 80% of all deaths (29 million) interventions needs active engagement from non-communicable diseases of sectors beyond health and a whole- occurred in low-income and middle- of-government, whole-of-society and income countries, and a higher health-in-all policies approach. proportion (48%) of the deaths in the latter countries are premature (under In 2008, the Health Assembly, in the age of 70) compared to high-income resolution WHA61.14, endorsed the countries (26%). The probability of action plan for the global strategy for dying from a non-communicable the prevention and control of non- disease between the ages of 30 and 70 communicable diseases, covering the years is highest in sub-Saharan Africa, period 2008–2013. That plan comprised Eastern Europe and parts of Asia. a set of actions that, when performed According to WHO‟s projections, the collectively by Member States and total annual number of deaths from other stakeholders, would tackle the non-communicable diseases will growing public health burden imposed increase to 55 million by 2030, if by non-communicable diseases. business as usual continues.1 Successful implementation of the plan
21
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
would need high-level political into account the outcomes of the High- commitment and the concerted level Meeting and the Moscow involvement of governments, Declaration on promoting healthy communities and health-care providers. lifestyles and control of non- The High-level Meeting of the United communicable diseases. In resolution Nations General Assembly on the WHA65.8 the Health Assembly also Prevention and Control of Non- endorsed the Rio Declaration on Social communicable Diseases and the Determinants of Health and urged adoption of the Political Declaration implementation of the pledges made therein. (United Nations General Assembly The draft action plan for the period resolution 66/2) represented a 2013–2020 seeks to consolidate the breakthrough in the global struggle contours of a plan for implementation against these diseases. For the first and follow-up of the outcomes of the time, all Member States of the United High-level Meeting with an updated Nations agreed that non-communicable global action plan for the prevention diseases constitute a major challenge to and control of non-communicable socioeconomic development, diseases into one document. The global environmental sustainability and monitoring framework, including poverty alleviation. The Political indicators and a set of voluntary global Declaration makes a clear call for targets for the prevention and control of including non-communicable diseases non-communicable diseases, have been in health-planning processes and the integrated into the draft action plan. development agenda of each Member STRUCTURE OF THE ACTION State. It also commits governments to a PLAN series of multisectoral actions and to Figure 1. Main elements of the action exploring the provision of adequate, plan predictable and sustained resources Vision through domestic, bilateral, regional A world in which all countries and and multilateral channels, including partners sustain their political and traditional and voluntary innovative financial commitments to reduce the financing mechanisms. avoidable global burden and impact of • Recognizing the leading role of WHO as the primary specialized agency for non-communicable diseases, so that health, and reaffirming the leadership role populations reach the highest attainable of WHO in promoting global action standards of health and productivity at against non-communicable diseases, the every age and those diseases are no Health Assembly requested the longer a barrier to socioeconomic Secretariat to prepare a follow-up plan for development. the outcomes of the High-level Meeting Overarching principles and approaches (resolutions WHA64.11 and EB130.R7), Human rights consistent with WHO‟s existing Non-communicable diseases are a strategies, building on lessons learnt from challenge to social and economic the 2008–2013 action plan for the global development strategy for the prevention and control of Universal access and equity non-communicable diseases and taking 22
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Life-course approach Set of voluntary global targets to be Evidence-based strategies achieved by 2025 Empowerment of people and Mortality and morbidity communities Premature mortality from non- Goal communicable diseases To reduce the burden of preventable (1) 25% relative reduction in overall morbidity and disability and avoidable mortality from cardiovascular diseases, mortality due to non-communicable cancer, diabetes or chronic diseases. respiratory diseases. Objectives RISK FACTORS Objective 1: To strengthen advocacy Behavioural risk factors and international cooperation and to (2) At least 10% relative reduction in raise the priority accorded to prevention the harmful use of alcohol,2 as and control of non-communicable appropriate, within the national context diseases at global, regional and national Physical inactivity levels and in the development agenda. (3) 10% relative reduction in Objective 2: To strengthen capacity, prevalence of insufficient physical leadership, governance, multisectoral activity. action and partnerships to accelerate Salt Sodium intake country response for prevention and (4) 30% relative reduction in control of non-communicable diseases. populations‟ mean intake of salt/sodium Objective 3: To reduce exposure to Tobacco modifiable risk factors for non- (5) 30% relative reduction in communicable diseases through prevalence of current tobacco use in creation of health promoting persons aged 15 years or older. environments. Biological risk factors Objective 4: To strengthen and reorient Blood pressure health systems to address prevention (6) 25% relative reduction in the and control of non-communicable prevalence of raised blood pressure or diseases through people-centred containment of the prevalence of raised primary care and universal coverage. blood pressure according to national Objective 5: To promote and support circumstances. national capacity for quality research Diabetes and Obesity and development for prevention and (7) Halt the rise in diabetes and obesity control of non-communicable diseases. Objective 6 :To monitor trends and National systems response determinants of non-communicable Drug therapy to prevent heart diseases and evaluate progress in their attacks and strokes prevention and control. (8) Receipt by at least 50% of eligible people of treatment with medicines and counselling (including control of glycaemia) to prevent heart attacks and strokes. Essential medicines and basic
23
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
technologies to treat major non- haematological, hepatic, communicable diseases gastroenterological, musculoskeletal, (9) 80% availability of affordable basic skin and oral diseases); (ii) mental technologies and essential medicines, disorders; (iii) disabilities, including including generics, required to treat blindness and deafness; and (iv) major non-communicable diseases in violence and injuries. both public and private facilities. The draft action plan explores potential Scope synergies between non-communicable Four categories of disease – diseases and interrelated conditions to cardiovascular diseases, cancer, maximize opportunities and efficiencies chronic respiratory diseases and for mutual benefit (Appendix 1). diabetes – make the largest 8. The actions for the Secretariat are contribution to morbidity and also in keeping with WHO‟s reform mortality due to non-communicable agenda, which requires the diseases and are the main focus of the Organization to engage an increasing draft action plan. These four non- number of public health actors, communicable diseases can be largely including foundations, civil society prevented or controlled by means of organizations, partnerships and the effective interventions that tackle private sector, in work related to shared risk factors, namely: tobacco prevention and control of non- use, unhealthy diet, physical inactivity communicable diseases. and harmful use of alcohol as well as This draft action plan also builds on the through early detection and treatment. implementation of the WHO These major non-communicable Framework Convention on Tobacco diseases and their risk factors are Control, the Global Strategy on Diet, considered together in the draft action Physical Activity and Health and the plan in order to emphasize shared global strategy to reduce harmful use of aetiological factors and common alcohol, and has close conceptual and approaches to prevention. strategic links to the draft There are many other conditions of comprehensive mental health action public health importance that are plan 2013–2020 (to be considered by closely associated with the four major the Sixty-sixth World Health non-communicable diseases, including: Assembly). (i) other non-communicable diseases (renal, endocrinal, neurological, GLOBAL MONITORING FRAMEWORK, INCLUDING INDICATORS, AND A SET OF VOLUNTARY GLOBAL TARGETS The global monitoring framework includes 25 indicators and a set of 9 voluntary global targets as shown in the folllowing table:. The action plan is geared to accelerate reduction in the burden of non-communicable diseases so that sufficient progress is made by 2020 to reach the global targets set for 2025. Framework element Target Indicator Mortality and morbidity Premature mortality (1) 25% relative reduction (1) Unconditional probability of dying 24
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
from in overall mortality from between ages of 30 and 70 from, non-communicable cardiovascular diseases, cardiovascular diseases, cancer, diabetes diseases cancer, diabetes, or chronic or chronic respiratory diseases respiratory diseases
Additional indicator (2) Cancer incidence, by type of cancer, per 100 000 population Risk factors Behavioural risk factors Harmful use of (2) At least 10% relative 3) Total (recorded and unrecorded) per alcohol:1 reduction in the harmful capita (aged 15 years and older) alcohol use of alcohol, as consumption within a calendar year in appropriate, within the litres of pure alcohol, as appropriate, national context2 within the national context (4) Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context (5) Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context
Physical inactivity (3) 10% relative reduction (6) Prevalence of insufficiently physically in prevalence of active adolescents (defined as less than 60 insufficient physical minutes of moderate-to-vigorous intensity activity activity daily) (7) Age-standardized prevalence of insufficiently physically active persons aged 18 years or older (defined as less than 150 minutes of moderate-intensity activity per week or equivalent) Salt/sodium intake (4) 30% relative reduction (8) Age-standardized mean population in mean population intake intake of salt (sodium chloride) per day in of salt/sodium intake3 grams in persons aged 18 years and older.
Tobacco use (5) 30% relative reduction (9) Prevalence of current tobacco use in prevalence of current among adolescents. tobacco use in persons aged (10) Age-standardized prevalence of 15 years and older . current tobacco use among persons aged 18 years and older. Biological risk factors
Raised blood (6) 25% relative reduction (11) Age-standardized prevalence of raised pressure in the blood pressure among persons aged 18.years prevalence of raised blood and older (defined as systolic blood pressure pressure or contain the >140 mmHg and/or diastolic blood pressure prevalence of raised blood >90 mmHg). pressure, according to national circumstances.
Diabetes and (7) Halt the rise in diabetes (12) Age-standardized prevalence of raised
25
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
obesity4 and obesity blood glucose concentrations/diabetes among persons aged 18 years and older (defined as fasting plasma glucose concentration > 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose concentration, respectively). (13) Age-standardized prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference as: overweight – one standard deviation body mass index for age and sex, and obese – two standard deviations body mass index for age and sex). (14) Age-standardized prevalence of overweight and obesity in persons aged 18 years and older (defined as body mass index greater than 25 kg/m² for overweight and 30 kg/m² for obesity).
Additional 15) Age-standardized mean proportion of total indicators energy intake from saturated fatty acids in ( persons aged 18 years and older. (16) Age-standardized prevalence of persons (aged 18 years and older) in population consuming less than five total servings (400 grams) of fruit and vegetables per day. (17) Age-standardized prevalence of raised total cholesterol concentration among persons aged 18 years and older (defined as total cholesterol concentration >5.0 mmol/l or 190 mg/dl) and mean total cholesterol concentration National systems’ response Drug therapy to (8) At least 50% of eligible (18) Proportion of eligible persons (defined as prevent heart people receive treatment aged 40 years and older with a 10-year attacks and with medicines and cardiovascular risk greater than or equal to strokes. counselling (including 30%, including those with existing control of glycaemia) to cardiovascular disease) receiving treatment prevent heart attacks and with medicines and counselling (including strokes. control of glycaemia) to prevent heart attacks and strokes. Essential (9) 80% availability of (19) Availability and affordability of quality, medicines and affordable safe and efficacious essential medicines for basic basic technologies and non-communicable diseases, including technologies to essential medicines, generics, and basic technologies in both public treat including generics, required and private facilities. to treat major non- communicable diseases in both public and private facilities. Additional indicators (20) Access to palliative care, as assessed by
26
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer. (21) Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate within the national context and national programs. (22) Availability, as appropriate, if cost- effective and affordable, of vaccines against human papillomavirus infection, according to national programs and policies. (23) Policies to reduce the impact on children of marketing of foods and nonalcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt. (24) Vaccination coverage against hepatitis B virus, monitored by the number of third doses of hepatitis B vaccine administered to infants. (25) Proportion of women between the ages of 30 and 49 years screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programs or policies. 1 Countries will select indicator(s) of harmful use of alcohol as appropriate to national context and in line with WHO‟s global strategy to reduce the harmful use of alcohol and that may include prevalence of heavy episodic drinking, total per capita alcohol consumption, and alcohol-related morbidity and mortality, among others. 2 In WHO„s global strategy to reduce the harmful use of alcohol the concept of harmful use of alcohol encompasses drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society. 3 WHO‟s recommendation is less than five grams of salt (sodium chloride) or two grams of sodium per person per day. 4 Countries will select indicator(s) appropriate to national context. 5 Individual fatty acids within the broad classification of saturated fatty acids have unique biological properties and health effects that can have relevance in developing dietary recommendations.
In the Holy Quran, Allah says: “Those who believe, and do deeds of righteousness, and establish regular prayers and regular charity, will have their reward with their Lord: on them shall be no fear, nor shall they grieve.” Prophet Muhammad (saws) said; “A believer is never satisfied in doing good until he reaches Jannah” (at-Tirmidhi) According to this hadith, when mankind is concerned about acquiring virtues and doing good deeds, he never tires of struggling for them and lives by them so intently until he reaches the end of his life; then his reward becomes his salvation from evil and attainment of heavenly peace. It is with this in mind that we struggle to achieve freedom of our souls and spirits to become better beings for our own sake the sake of others and defeat illhealth of the mind and body.
27
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
A Global Action for Promoting a Healthy Diet (Within the Scope of the Action Plan for Prevention and Control of NCD)
The proposed action is to advance the food products (fruit and vegetables, products implementation of global strategies and with reduced sodium content, saturated fatty recommendations. It urges member States to acids, trans-fatty acids, free sugars); consider developing or strengthening national (d) To ensure the provision of healthy food in nutrition policies and action plans and all public institutions and in workplaces; implementation of the Global Strategy on Diet, Physical Activity and Health, the global (e) To consider economic tools, including strategy for infant and young child feeding, taxes and subsidies, to improve the the comprehensive implementation plan on affordability of healthier food products and to maternal, infant and young child nutrition and discourage the consumption of less healthy the implementation of WHO‟s set of options;6 recommendations on the marketing of foods (f) To conduct public campaigns and social and non-alcoholic beverages to children, and marketing initiatives to inform consumers other relevant strategies. about healthy dietary patterns and to facilitate healthy behaviours; This action includes introducing policies and actions aimed at promoting (g) To create health and nutrition promoting interventions for healthy diets in the entire environment in schools, work sites, clinics and population, as follows: hospitals, including nutrition education; (a) To promote and support exclusive (h) To implement the Codex Alimentarius breastfeeding for the first six months of life, international food standards for the labelling continued breastfeeding until two years old of pre-packaged foods as well as the Codex and beyond and adequate and timely Guidelines on Nutrition Labelling in order to complementary feeding; develop policy provide accurate and balanced information for measures directed at food producers and consumers that enables them to make well- processors: informed, healthy choices;7 (b) To develop policy measures directed at (i) To implement WHO‟s set of food producers and processors: recommendations on the marketing of foods • To reduce the level of sodium in food and non-alcoholic beverages to children, including mechanisms for monitoring. • To eliminate industrially produced trans-fatty acids from food and to replace them with polyunsaturated fatty acids • To decrease the level of saturated fatty acids in food and to replace them with polyunsaturated fatty acids • To reduce the content of free sugars in food and non-alcoholic beverages; (c) To develop policy measures directed at food retailers and caterers to improve the accessibility and affordability of healthier
28
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Section II Original Research Studies ______An Intervention to Reduce Exposure of Neonates to Environmental Tobacco Smoke by Exclusive Breastfeeding Neveen Tawfik Abed, MD*, Nevien Waked MD****, Azza MAM Abul-Fadl MD*, Hala ElHady**, Mostafa ElSayed Mostafa^ Pediatric Department*, Community Medicine Department** Benha Faculty of Medicine, Benha University with Sixth of October Faculty of Medicine**** ______Abstract Background: Exposure of infants and children to environmental tobacco smoke (ETS) can have deleterious effects on their growth and development. Strategies to protect breastfed infants from the hazardous effects of ETS need to be addressed. Aim: To assess the effects of ETS on the health growth and development of young infants and identify interventions that can be useful in decreasing the hazardous effects of ETS. Methods: One hundred and fifty infants aged 2-3 months were assessed according to feeding modality for growth by weight-for-age (W/A), supine length-for-age (L/A) and head circumference for age (HC/A) and hemoglobin concentrations. They included 50 exclusively breastfed, 50 partially breastfed who received other milks and 50 receiving only formula or cows milk from birth. Of these, 50 infants who were partially breastfed, were exposed to an intervention for increasing milk supply and reverting to exclusive breastfeeding. Blood hemoglobin levels and serum Cotinine levels were measured before and after exposure to the intervention using qualitative methods. Findings: Weight and head circumference measurements were statistically significantly higher in the exclusively breastfed group as compared to fully artificially fed. Respiratory and diarrheal disease were significantly lower in infants exclusively and partially breastfed despite exposure to ETS. Hemoglobin levels were significantly lower in those exposed to any formula feeding. Although the intervention group showed increased Cotinine levels in the blood, yet their growth and health status improved significantly. Conclusions: Exposure to the hazardous effects of ETS can be reduced by intensive breastfeeding practices. It appears that the diuretic effect of intensive breastfeeding practices can promote the excretion of the toxic compounds of ETS. Women should be empowered educationally and socially to protect themselves and their babies from passive smoking. Laws and religious preachers that incriminate exposure of babies to ETS need to be effected. ______
29
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
addition to promoting intellectual and immunological development (7). Introduction Formula feeding has been proven to Exposure to environmental tobacco be associated with higher rates of smoke (ETS) is a major world-wide morbidity from communicable and non communicable disease and public health problem and a real risk (8) to child health (1). Tobacco contains malnutrition . Still there is concern over 3,000 chemicals of which over that breastfeeding can increase exposure to ETS by passage through 200 are regarded as poisons and 50 as (9,10) possible carcinogens, it is generally breastmilk and inhalation . accepted that there is no safe level of Hence the aim of this study is to exposure to cigarette smoke (2). The compare the effect of ETS on the majority of ETS occurs within the health and growth of infants exposed home mainly from parental smoking to different types of feeding (3). Mothers‟ smoking has been shown modalities. Also to test the impact of to be the most harmful. Around 41% modification of infant feeding of pregnant women suffered ETS by practices on ameliorating the effects their husbands and 42% reported of passive smoking in infants exposed working in smoky environment. to suboptimal feeding practices. Maternal smoking in pregnancy is Subject and Methods: associated with adverse pregnancy This is a cross sectional, prospective outcomes, including an increased risk cohort study carried out with 150 children for preterm birth, placental abruption, exposed to passive smoking divided into 3 groups according to the following placenta previa, and low birth weight. feeding modalities: the first group (50) This may have life-long consequences was exclusively breastfed from birth to that points to a significant pediatric the age of presentation, the second group and adult morbidity associated with (50) was partially breastfed and the third reduced birth weight (4,5). group (50 was not breastfed and was fed Children‟s exposure to ETS is on infant formula milk (IFM) or other associated with a number of poor animal milk. child health outcomes as increased Selection of cases: The 150 cases were incidence of middle ear disease, randomly selected based on the following conductive deafness, asthma wheeze, inclusion and exclusion criteria: Inclusion criteria included 1) Full term cough, bronchitis, bronchiolitis, normal healthy infant. 2) Aged 2-3 pneumonia and impaired pulmonary months; 3) Exposed to direct smoking function. It has also been associated (Tobacco or Shisha) from a close family with snoring, adenoid hypertrophy, member at home (mother or father or tonsillitis, sore throats and sudden family member living in the same house); infant death (6). and with healthy mothers free from any Breastfeeding is associated with chronic disease or disabling condition. protection against acute respiratory Exclusion criteria included preterm infections and diarrheal disease, in infant, presence of major congenital 30
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
anomalies, babies with chronic diseases The interventions consisted of the as (liver or kidney or etc or receiving following: chronic medications or supplements, also Discontinuation of all bottles or pacifier babies with no direct exposure to smoke or supplements (caraway – yansoun – or mothers with chronic diseases or under milk) offered to the baby, whilst medications. increasing the frequency (8-12 times/day) The mothers were asked to complete an and duration (unrestricted, unlimited, Arabic questionnaire, which included intensified breastfeeding) with at least 3 information about the education and feeds during the night time. Mothers were occupation of both parents, the number of instructed to feed to cue or let the baby babies in the family, income of the decide when to leave the breast. family, health status of the mother, Mothers were shown the correct methods breastfeeding status of the infants, of milk expression and advised to express smoking status of mother, father and milk between feeds (at least 3 times /day other family members, type of family, sex between long feeds) and increase her of infant, start of formula feeding, and fluid intake up to 2-3 liters /day. She was total number of cigarettes smoked at prescribed natural lactagogues for home per day. increasing milk supply or Domperidone Evaluation of the infant included age of (motilium) if she needed to be relactated. the infant, feeding practices and prenatal The latter was determined by the history of the child. The anthropometric frequency of bottle feeding so if the measures included body weight to nearest mother fed 2 bottles or more, she was gram, supine length to nearest mm and prescribed motilium, 2 tablets tid /day for head circumference to nearest mm. The 10-14 days and assessed closely at health status included frequency of chest weekly intervals. She was encouraged to infection and hospitalizations, also increase skin to skin care before and after diarrheal disease and number of attacks each feed to sooth baby when crying to and association with or without increase milk supply. All mothers were dehydration and hospitalization. assessed for ensuring correct attachment All mothers of the partially breastfed and positioning at breast using UNICEF group were informed of the benefits of and WHO breastfeeding observation form increasing the frequency of breastfeeding in smaller babies. and its effect in reducing hazards of Mothers were also encouraged to increase smoking and improve general health of their intake of fruits and vegetables rich the child by using educational methods. in vitamin C and were prescribed vitamin Mothers from this group who were C supplement of one gm/day. willing to go back to exclusive Blood samples were drawn and measured breastfeeding were guided to follow the to determine Hemoglobin in gm/dl and protocol (intervention) under testing for serum Cotinine level in each infant. reducing nicotine level in the blood. If Serum samples taken from the infants for mother agreed the blood samples were Cotinine measurements were kept at 8- drawn and mother was followed up at 10°C until analysis. Cotinine weekly intervals then at 2-3 weekly measurement was performed by (rapid intervals for the next 6 weeks. At the end kits of Sigma Company. Cotinine level of 6-8 weeks another blood sample was was obtained as qualitative measure (-ve, drawn. +ve, ++ve, +++ve).
31
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Statistical analysis: the cutoff of exclusive breastfeeding (after the significance was taken as p<0.05. intervention) P<0.05. Student‟s t-test for independent samples Table (8) demonstrates that the Cotinine was used for the comparison of the means serum levels were higher in the partially of two groups; Chi-square test was used breastfed groups who reverted to for comparison of two groups. exclusive breastfeeding (after the Results intervention) P<0.001. Those who The results are shown in tables 1 to 9 as showed significantly higher levels were follows: mostly those exposed to Shisha smoke. Table (1) shows that infants exclusively Discussion breastfed gained weight more than the This study was primarily designed to artificially and partially breastfed infants. assess the level of serum cotinine, as The difference was statistically a reliable qualitative marker of significant at P<0.05. Table (2) shows exposure to ETS, to use it as indicator that the head circumference was of the intensity of exposure to ETS statistically significantly higher in exclusively breastfed infants than and a marker to detect changes in artificially and partially breastfed. The growth measurements, hemoglobin mid arm circumference was statistically levels and health status including significantly higher among the frequency of chest, skin and exclusively breastfed infants compared to gastrointestinal (GIT) infections the artificially and partially breastfed. among infants exposed to ETS. Table (3) shows that the hemoglobin We found that there was a significant level was statistically significantly higher relationship between the mode of in exclusively breastfed infants than feeding and growth rate as assessed artificially and partially breastfed at by weight and length for age. Several P<0.001. Table (4) showing that infants exclusively workers have shown that extending breastfed had less episodes of severe exclusive breastfeeding to six months chest infections than artificially and was found to accelerate weight and partially breastfed but the difference was length gain and improve motor not statistically significant. development of infants. It also Table (5) demonstrates that diarrheal improved maternal nutritional status disease was less in exclusively breastfed by preventing and conserving nutrient infants than artificially and partially loss by the amenorrheaic effect of breastfed but the difference was not exclusive breastfeeding (11,12). statistically significant. Table (6) Exclusive breastfeeding from birth up demonstrates a reduction in the episodes of chest infection in the groups that to six months of age was associated reverted from being partially breastfed to with a significant reduction of being exclusively breastfed infants respiratory and gastrointestinal P<0.05. morbidity in our group of infants Table (7) demonstrates that the frequency despite exposure to ETS. Our findings of diarrheal episodes were less in the are in agreement with the findings of partially breastfed groups who reverted to several workers and the global health policies that recommend extending 32
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
exclusive breastfeeding to six months effect (18). This most probably (7,11). explains the higher ability of these The pattern of breastfeeding had a infants to excrete these toxic significant effect on hemoglobin compounds from their body as level. Similar results were found by compared to those not breastfed (19). Marlúcia(13) who reported that In a study on babies who were exclusive breastfeeding during the formula fed as compared to those first six months of life was associated who were breastfed the rennin- with the highest levels of hemoglobin aldosterone-angiotensin (RAA) followed by those predominantly system of formula fed was found to breastfed. While other workers found be impaired with high renin levels that anemia prevalence rates observed and was associated with impaired among infants aged between 3 and 6 urinary elimination of salts and months justified increased attention probably other compounds. While on the part of pediatricians to monitor fully breastfed infants had a fully hemoglobin levels of infants who are developed RAA system, normal fully breastfeeding especially those levels of these hormones that coming from low-income families as correlated well with their ability to they present nutritional and handle and excrete electrolytes (19). behavioral risk factors for iron Exposure to ETS could influence deficiency (14). breastfeeding either by an effect on The effect of maternal smoking on prolactin production which has been breastfeeding duration was described documented for maternal smoking or by several authors (15). Moreover perhaps by changing the taste of studies showed that smoking reduces human milk such as garlic, mint or daily milk output about 250-300 ml vanilla making it less palatable to (16). A probable mechanism for this children (20, 21). effect is the increase of dopamine Both maternal smoking and ETS may secretion in the hypothalamus leading increase the frequency and severity of to a reduction in prolactin levels (17). respiratory infections(22,23), thus The presence of Nicotine and affecting the child‟s appetite and Cotinine in the breast milk of nursing leading to reduced nipple stimulation mothers has been documented (8). and lower milk production(21, 24). ETS in these infants is likely to be a It was clear from our current study combination of inhaled and ingested that even though all the infants under Nicotine (20, 21) . study were exposed to ETS, still the Breast fed infants of smoking exclusively breastfed babies fared mothers reported urine Cotinine level better showing a higher potential for 10 folds higher than bottle fed infants growth in weight and head whose mothers smoke, probably circumference and reduced episodes correlated with the frequency of of chest infections and diarrheal breastfeeding, enhancing its diuretic disease when compared to infants
33
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
exposed to infant milk formula or should not be given away for cow‟s milk. Although reversion to smoking, neither does her partner of full breastfeeding in the intervention family members have the right to group resulted in a significant harm her or her baby by exposing increase in the serum Cotinine, still them to ETS(27, 28, 29, 30).. Smoking and infection rates decreased and overall exposure to ETS has a negative effect growth was improved. This is in line on prolactin and milk production, with findings of other workers(25, 26). shortening breastfeeding duration and Our current intervention was influencing milk production and introduced to enhance excretion of child's future growth and the toxic compounds from ETS by development. increasing fluid intake and thereby Mothers exposed to ETS should be dieresis include intensive encouraged to exclusively breastfeed breastfeeding, frequent expression of and increase the intensity and milk, increased intake of fluids and exclusivity of breastfeeding to Vitamin C intake. This is supported enhance prolcactin secretion and by the findings of other workers who assist in eliminating the nicotine from reported that breast fed infants of their body. Moreover every effort smoking mothers have urine Cotinine must be made to decrease maternal level 10 folds higher than bottle fed smoking and exposure of mothers and infants whose mothers smoke infants to ETS whether second hand indicating increased excretion rates in or third hand smoke (32). these infants who were breastfed(18). Such interventions were shown References effective as they not only improved 1. Berridge V. (2004) Passive smoking and its pre-history in Britain: Policy speaks to the success rates in return to full science. Soc.Sc. Med. 49 (9): 1183-1195. breastfeeding but also had a positive 2. Grazuleviciene R, Danileviciute A, effect on the growth and overall Nadisauskiene R, and Vencloviene J. health of children despite increase in (2009) Maternal Smoking, GSTM1 and the Cotinine levels. GSTT1 Polymorphism and Susceptibility to Adverse Pregnancy Outcomes. Int J In conclusion the proven effects of Environ Res Public Health. 6(3): 1282– breastfeeding are innumerable as it 1297. protects infants from respiratory 3. Blackburn CM, Bonas S, Spencer NJ, Coe infections that results from exposure CJ, Dolan A and Moy R (2005): Parental (22,23) smoking and passive smoking in infants: to ETS and influences child Fathers matter too Health Educ. Res. growth and development and 20:185-194. particularly brain development (23-26). 4. Krisela S., Thea de Wetb, Yussuf Smoking is hazardous to breastfed S.,Hannelie NDY.(2006): The influence of babies and every effort to encourage maternal cigarette smoking, snuff use and passive smoking on pregnancy outcomes. mothers to stop smoking during Pediatric and Prenatal Epidemiology. pregnancy and breastfeeding should 20:90–99. 59-71. be made, the gift of nurturing a child
34
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
5. Bernstein I.M. Mogen J.A., Badge G.J. 15. Mansbach JM, Piedra PA, Teach SJ, et al. Solmon L., Heil S.H and Higgins (2005): (2012) Prospective multicenter study of Maternal smoking and its association with viral etiology and hospital length of stay birth wight, Obst and Gyn. 106:986-991. in children with severe bronchiolitis. Arch 6. Gurkan F, Kiral A, Dagli F and Karakoc F Pediatr Adolesc Med. 166(8):700-706. (2000): The effect of passive smoking on 16. Hopkinson JM. et al. (1992) Milk the development of respiratory syncytial production by mothers of premature virus bronchiolitis. European journal of infants: influence of cigarette smoking. Epidemiology. 16:465-468. Pediatrics. 90(6):934-938. 7. Dewey KG, Cohen RJ, Brown KH, Rivera 17. Andersen AN, Lund-Andersen C, Larsen LL. (2001) Effects of exclusive JF, et al.(1982) Suppressed prolactin but breastfeeding for four versus six months normal neurophysin levels in cigarette on maternal nutritional status and infant smoking breast-feeding women. Clin motor development: results of two Endocrinol.17:363–368. randomized trials in Honduras.J Nutr. 18. Mascola M A, Van Vunakis H, Tager IB, 131(2):262-7. Speizer FE, Hanrahan JP. (1998) 8. Barbara H. and Marly A. (2009): Infant Exposure of young infants to feeding practices, childhood growth and environmental tobacco smoke: obesity in adult life. Arq Bras Endocrinal Breastfeeding among smoking mothers. Metab. 53(5):528:39. American Journal of Public Health. 9. Dahlström A, Lundell B, Curvall M, 88(6):893–896. Thapper L. (1990) Nicotine and cotinine 19. Amer E, Mohamed ZM, Abul-Fadl AM, concentrations in the nursing mother and Fadaly N, Abul-Fadl MAM. (2012): her infant. Acta Paediatr Scand. Plasma rennin activity and aldosterone 79(2):142–147.[PubMed] level in breastfed and bottle fed in the first 10. Labrecque M, Marcoux S, Weber JP, year of life. Eg. J Breastfeeding. 6:97-106. Fabia J, Ferron L. Feeding and urine 20. Mennella JA. (2005) Mothers milk a cotinine values in babies whose mothers medium for early flavor experiences. J smoke. Pediatrics. 1989 Jan;83(1):93– Hum Lactation. 11: 39-45. 97.[PubMed 21. Horta B.L., Kramer M.S., Platt 11. Kramer MS, Kakuma R. (2012) Optimal R.W.(2001) Maternal smoking and the duration of exclusive breastfeeding. risk of early weaning: a meta-analysis. Cochrane Database Syst Rev. 15;8 Am J Public Health. 91:304–307. 12. Kramer MS, Chalmers B, Hodnett ED, 22. Bakoula CG, Kafritsa YJ and Kavadias Sevkovskaya Z, Dzikovich I, Shapiro S, et GD. (2009) Objective passive smoking al., PROBIT Study Group (Promotion of indicators and respiratory morbidity in Breastfeeding Intervention Trial). (2001) young children. Lancet. 346:280-281. Promotion of Breastfeeding Intervention 23. DiFranza JR, C. Aligne A, Weitzman Trial (PROBIT): a randomized trial in the M.(2004) Prenatal and Postnatal Republic of Belarus. JAMA. 24-31; Environmental Tobacco Smoke Exposure 285(4):413-20. and Children‟s Health Pediatrics. 1007- 13. Marlúcia OAA, Nunes GE, Gecynalda G, 1015. de Cássia RR, Szarfarc SC, Souza SB 24. Diaz S., Herreros C., Aravena R., et al., de.(2004) Hemoglobin concentration, (1995): Breastfeeding duration and growth breastfeeding and complementary feeding of fully breastfed in a poor urban Chilean in the first year of life. Rev. Saúde population American Journal of clinical Pública. 38(4): 543-551. nutrition. 62:371-6. 14. Torres MAA ., Braga JAP., Taddei JAC., 25. Schack-Nielsen L and Michaelsen KF. Nóbrega FJ. (2006) Anemia in low- (2006) Breastfeeding and future health. income exclusively breastfed infantsJ Curr Opin Clin Nutr Metab Care. Pediatr (Rio J). 82(4):284-8 9(3):289-96.
35
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
26. Reynolds A. (2001): Breastfeeding and in the lungs. Am. J. Respir. Crit. Care brain development. Pediatr Clin North. 48 Med. 181, A1425. (1):159-171. 30. Burke V., Gracey M.P., Milligan R.A. 27. Horta, BL, Victora, CG, Menezes, AM (1998) Parental smoking and risk factors and Barros, FC. (2007) Environmental for cardiovascular disease in 10- to 12- tobacco smoke and breastfeeding duration. year-old children. J Pediatr. 133:206–213. Am.J.of Epidemiol. 543-553. 31. Becker AB, Manfreda J, Ferguson AC, 28. Bachour P., Yafawi R., Jaber F., Choueiri Dimich-Ward H, Watson WTA, Chan- E., and Abdel-Razzak Z. (2012) Effects of Yeung M. (1999) Breast-feeding and Smoking, mother's age, Body Mass Index, environmental tobacco smoke exposure. and parity number on lipid, protein, and Archives of Pediatrics & Adolescent secretory immunoglobulin A Medicine. 153:689–691. concentrations of human milk. 32. Johansson A, Hermansson G, Ludvigsson Breastfeeding Medicine. 7(3): 179-188. J. (2004) How should parents protect their 29. Hansdottir S., Monick M. M., Lovan N., children from environmental tobacco- Powers L. S., Hunninghake G. W. (2010). smoke exposure in the home? Pediatrics. Smoking disrupts vitamin D metabolism 113(4):e291–e295
Table (1) Comparing weight in grams in the infant groups with different modes of feeding modality:
Variable Groups Mean ± SD Range Student t P (gms) test value Exclusive 3900- 5100 breastfed 700 6600 0.001 3.617 Artificially 650 3600- HS 4610 fed 6400 Artificially 650 3600- 4610 Weight fed 6400 0.014 2.51 (gms) Partial 560 3900- S 4920 breastfed 6000 Exclusive 700 3900- 5100 breastfed 6600 0.153 1.44 Partial 560 3900- NS 4920 breastfed 6000
36
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Table (2) Comparing head circumference measurements (in cm) in the infant groups with different modes of feeding modality:
Variable Groups Mean ± SD Range Student t P value (cm) test
Exclusive 1.07 39.47 38-42 breastfed 0.001 3.78 Artificially 1.16 HS 38.62 37-42 fed Artificially 1.16 38.62 37-42 Head fed 4.44 0.001 HS circumference Partial 1.17 39.66 38-42 in cm breastfed Exclusive 1.07 39.47 38-42 breastfed 0.395 0.855 Partial 1.17 NS 39.66 38-42 breastfed
Table (3) Comparing the hemoglobin level in gm/dl in infant groups with different modes of feeding modality:
Variable Groups Mean ± SD Range Student t P value (gm/dl) test Exclusive 0.52 10.23 9.3-11.5 breastfed 0.001 5.41 Artificially 0.75 HS 9.53 8-11.2 fed Artificially 0.75 9.53 8-11.2 Hb level fed 0.845 0.40 NS (gm/dl) Partial 0.67 9.65 8.4-11.2 breastfed Exclusive 0.52 10.23 9.3-11.5 breastfed 0.001 4.83 Partial 0.67 HS 9.65 8.4-11.2 breastfed
37
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Table (4) Comparing frequency distribution of exposure to chest infections in infant groups with different modes of feeding modality:
Exclusive Artificially Partial Total X2 P Chest breastfed fed breastfed test value
No % No % No % No % Infection No 45 90.0 37 74.0 37 74.0 119 79.3 5.21 0.074 NS Yes 5 10.0 13 26.0 13 26.0 31 20.7
Total 50 100.0 50 100.0 50 100.0 150 100.0
Table (5) Comparing frequency distribution of exposure to diarrheal disease in the study groups. Exclusive Artificially Partial Total X2 P breastfed fed breastfed test value
No % No % No % No % Diarrhea No 45 90.0 40 80.0 39 78.0 124 82.7 2.89 0.24 NS Yes 5 10.0 10 20.0 11 22.0 26 17.3 Total 50 100.0 50 100.0 50 100.0 150 100.0
Table (6): Comparing frequency distribution of exposure to chest infection in the group of intervention group at 2 and 4 month (before and after the intervention): Chest Before (2mo) After (4mo) Total Z test P value
Infection No % No % No % No 37 46.8 42 53.2 79 100.0 0.56 0.29 NS Yes 13 61.9 8 38.1 21 100.0 1.123 0.13 NS Total 50 50.0 50 50.0 100 100.0 0.0 0.5
38
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Table (7) Comparing occurrence rates of diarrheal episodes before and after the intervention in the group of partially breastfed at 2 and 4 month: Before (2mo) After (4mo) Total Z test P value Diarrhea No % No % No % No 39 47.6 43 52.4 82 100.0 0.44 0.33 NS Yes 11 61.1 7 38.9 18 100.0 0.967 0.167 NS
Total 50 50.0 50 50.0 100 100.0 0.0 0.5 NS
Table (8) Comparing serum Cotinine level in the intervention group of partially breastfed infants at 2 and 4 month (before and after the intervention):
Before (2mo) After Total Corrected P (4mo) X2 test value
No % No % No %
Negative 24 49.0 3 9.1 27 32.9 22.84 0.001 HS + 15 30.6 11 33.3 26 31.7 ++ 10 20.4 12 36.4 22 26.8
+++ 0 0.0 7 21.2 7 8.5
Total 50 100.0 50 100.0 100 100.0
39
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
دراسة للتدخل بواسطة الرضاعة الطبٌعٌة المطلقة لحماٌة الرضع من آثار التدخٌن السلبً زٌذوٛؽسظ/ ١ٔف١ٓ ٛؼف١ك عسضذ* ‘ زٌذوٛؽسظ / ١ٔف١ٓ ٚزوذ** ، زألعؽسرظ زٌذوٛؽسظ /عضظ أضٛ زٌفعً *، زألعؽسرظ زٌذوٛؽسظ/ ٘سٌع زٌٙسدٞ ***؛ زٌذوٛؽس/ ِصطفٝ زٌغ١ذ ِصطفٝ^ * **قسٌ غب األغفبه ميٞة اىطب بْٖب- خبٍعة بْٖب ، قسٌ غب األغفبه ميٞة اىطب 6 أمح٘بش خبٍعة 6 أمح٘بش *** قسٌ غب اىَدحَع ميٞة غب– خبٍعة بْٖب ،^ ٗصاسة اىصسة ______الخلفٌةةة : أوددذغ زٌذسزعددسغ زٌة١ٍّددع أْ تعرر ال ضررو األطفرر للرردخ ن االبيئرر )الترردخين البررلب يتببب ف آث ج نبية خطي ة بر ا ً ا نر ق يبرة بعيردة الىرد علر نىر م تطر م ، علر ال غم ىن الجه د الىبذ لة للحد ىنه بإصردا الور انين لألىر ان الخ ليرة ىرن التردخين العو بر لىن يخر ل ذلر، ،إال أن ىصر ى زالر ىرن أاثر الرد إنتشر ا لهرذا البرل ، الضر ب لصرحة لعدم اإللتزام ب ل ابط النظم لتطبيق ذه البي بة لذا جب البحث عرن ابرت اتيجي لحى يرة ال ضو الىتع ضين له لجه أ إ ى أ تعىد أ بلب إ ادة ىن ح لهم . اىٖذف: إبتهدف الد ابة توييم آث التدخين البلب عل صحة نىر األطفر الصرر تحديرد التدخال الت يىان أن تا ن ىفيدة ف خف اآلث ه الخط ة عليهم . غررشا اىثسرر : تررم تويرريم ى ئررة خىبررين ضرريو الررذين تترر ا م أعىرر م ىرر بررين 2-3 أشرره فورر ٌطش٠مع الترذيرة ىرن حيرث الر زن ب لنبربة للعىر ، الطر ب لنبربة للعىر ِىدػ١ زٌدشأط ب لنبربة للعى الهيى جل بين. ا ن ىن بينهم 55 ي ضع ن ض عة طبيعية ىطلوة 55 عل ض عة جزئيررة ىررن الررذين حصررل ا علرر حليررب صررن ع 55 غفددً بترررذ ن علرر اللرربن الصررن ع ىررن ال الدة. ، قد تع 55 ِٓ ال ضو الذين حصل ا علر ضر عة طبيعيرة جزئير إلر التردخ لزي دة إنت ج الحليب زٌةٛدظ جٌدٝ ال ضر عة الطبيعيرة الىطلورة ىرو قير ىبرت ي الار تينين قبر بعد التع لهذا التدخ ِٚمسسٔع وسٙؽٌُ زٌصى١ع لطً ٚضةذ زؽٌذخً. النتةةا: أ ضررح النترر ئ إ تفرر إحصرر ئ فددٟ ِةددذيغ ل١سعددسغ الرر زن ِىددػ١ الرر أ فرر ىجى عررة ال ضرر عة طبيعيررة الىطلوررة ب لىو نررة إلرر ذ يهررم عٍددٝ زؽٌغز٠ددع الصررن عية. اىرر ارر ن تع ضهم ألى ا الجه ز التنفب زإلعٙسي أق باثي عل ال غم ىن التع للدخ ن البلب . ا ن ىبت ي الهيى جل بين أق باثي فر أ لئر، الرذين يتع ضر ن إلر أ الترذيرة زٌصدٕسع١ع عل ال غم ىن أن ىجى عة التردخ أظهر زير دة ىبرت ي الار تينين فر الردم، إال أن حر لتهم الصحية تحبن اى أظه تحبن فٟ النى بشا ىلح ظ. الخالصة التع للدخ ن البلب خط لل ضو البد ىن حى يتهم ب ل ض عة الطبيعية الىطلورة الىاثفررة الترر تبرر عد علرر زيرر دة إد ا البرر ب لترر ل الررتخل ىررن الى ابرر البرر ىة الترر يتع لهر ال ضريو أىر . علر الر غم ىرن ذلر، فإنر يجرب ت عيرة األىهر ترد يبهن علر الىط لبة بحو قهن أطف لهن ىو اإللتزام بور انين ىنرو التردخين فر األىر ان الع ىرة الىرلورة أن يا ن ن ، جه ز ش ط لى اقبة تفعي الو انين العو ب الخ صة بذل،. ______
40
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Delay of Early Prefeeding Responses in Cesarean Delivery Interferes with Outcome of Breastfeeding at Discharge Mohsen Khairy MD**, Doaa ElRefaey MD*, Mohammed Abd el Fattah ElSayed, MSc.*, Azza MAM Abul-Fadl MD*.
*Pediatric and **Obstetric Department of Benha Faculty of Medicine, Benha University ______Abstract Introduction: The mechanism by which the mode of delivery can influence the outcome of timely breastfeeding initiation is not clearly defined. The discovery of prefeeding responses over the past decade has raised much interest in the factors influencing early initiation of breastfeeding. Aim: to assess the effect of mode of delivery on the early first hour prefeeding responses and timely initiation of breastfeeding. Methodology: This is a prospective cross sectional observational study including 100 women delivered by vaginal delivery (NVD) and 100 by cesarean section (C-S) using spinal anesthesia by heavy bupivacaine. They were offered skin to skin at birth during which the prefeeding responses were observed and recorded by time of appearance in both groups. The intervention consisted of support and guidance in breastfeeding at discharge, 2 weeks, and 3 month, conducted for 50 NVD and 50 C.S. The other one hundred mother infant pairs did not receive support. Findings: Timely initiation in the first hour occurred in was significantly delayed in cesarean section exposed to spinal anesthesia and mostly in the unsupported group (8.6%) compared to the supported vaginal group (28%) at P<0.05. 25 Pre-feeding responses: were observed but were delayed in groups exposed to anesthesia. Supported mothers were more likely to exclusively breastfeed at 3 months than the unsupported group, (60% vs. 45% P value= 0.002). Conclusions: Exposure to cesarean section interferes with timely initiation of breastfeeding by delaying the appearance of prefeeding responses. Hence the importance of encouraging mother friendly practices that promotes normal delivery. ______Introduction through the immune rich liquid gold, The birth of a neonate is the most colostrum and warmth, preventing powerful miracle of mankind. Birth hypothermia which is especially triggers a series of maternal infant important for small and low birth behaviors that end with the weight babies (1). In addition the baby spontaneous unaided breastfeeding is less stressed, calmer and has when the baby is placed skin to skin steadier breathing and heart rates and (STS) with the mother. Mother's body thereby less likely to develop ashyxia provides baby with nourishment (2). Moreover the newborns that have
41
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
been exposed to SSC maintain The sample included one hundred women adequate blood glucose levels, and delivered by vaginal delivery (NVD) and have better metabolic adaptation (3). one hundred admitted for cesarean Despite all these vital and life saving section (C-S). Both groups were matched benefits early STS has been for age and socioeconomic status. All of whom were explained the benefits and challenged by operative interventions draw backs of the intervention and who that impede nature's course of events gave their verbal consent to participation in establishing mother infant bonding in the study in line with the ethical behavior. Also the use of anesthetic criteria for conducting research studies. agents administered to the mother that Inclusion criteria included women at crosses the placenta and cause fetal delivery (nulliparous or multiparous), age and neonatal depression. Systemically 15-49 years, general or spinal anesthesia administered agents cross the placenta for those who deliver by C-S, women to a greater degree than non-systemic giving birth to normal term single baby, agents (4). Parenteral narcotics can be no anesthesia received for those who deliver by NVD. associated with neonatal respiratory Exclusion criteria included females depression, decreased neonatal whose pregnancy consisted of multiple alertness, inhibition of sucking, and a babies, neonatal complications; (5) delay in effective feeding . premature or babies admitted in an However the extent to which mode of intensive care unit; babies with major delivery interfere with early initiation congenital anomaly or major birth injury; of breastfeeding is poorly understood women who had a complicated birth or (6). Moreover it is not clear whether severe complications during pregnancy. supporting the mother to initiate The two hundred women were classified breastfeeding through skin to skin according to the mode of delivery, exposure to anesthesia, support and contact may reduce the deleterious follow up after birth into the following 4 effects of operative delivery on the subgroups: group 1 included fifty women success of breastfeeding. Hence our exposed to anesthesia and cesarean aim, in this research, is to study the section who were supported during effect of mode of delivery on early delivery and during follow up for 3 initiation of breastfeeding. Also to months; group 2 included fifty women study the effect of mode of delivery exposed to anesthesia and cesarean on the pre-feeding reflexes and section and not offered support during breastfeeding outcome at discharge. delivery and follow up; group 3: included fifty women not exposed to Subjects and methods anesthesia and delivered vaginally and This is a prospective cross sectional non- supported during delivery and during randomized observational study follow up for 3months and group 4: conducted with two hundred women from included fifty women not exposed to January of 2012 to May of 2012 selected anesthesia during delivery (normal from a mixture of tertiary Cairo vaginal delivery) with no support at governorate hospitals including hospitals delivery or during follow up. representing Universities, teaching organization, public, and private sectors. 42
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Sample selection: 20 NVD and 20 C-S general or spinal anesthesia, hazards of cases were selected from each of the formula feeding, special supplemental following hospitals Kasr-Al-Aini nutrition program for women, University Hospital, Al Galaa Teaching, breastfeeding support. The mother was Shubra General Hospital, Al Zawia also informed and educated about the General Hospital, and Al-Fatteh private importance of breastfeeding in general, Hospital. The hospitals were chosen the technique and the benefit of early skin because they fit the criteria of having to skin care (SSC) between the mother turnover of normal vaginal delivery and her newborn as a mean to successful (NVD) and cesarean section (C.S) births. initiation of breastfeeding. Step 3: Interviews were carried with the Observation of the mother-infant pairs anesthesia specialists of the different in the delivery or operation room: In the hospitals under study to define the drugs delivery or operation room information used as anesthetic drugs. about the mother and the baby was This protocol used in all the hospitals for collected including: weeks gestation, sex, all the cases selected was unified as birth type, analgesia given during labour, follows: General anesthesia: A- narcotics given, spinal or general Intravenous anesthesia: Thiopental Na or anesthesia, induction of labour, Propofol for women suffering from meconium liquor, weight of the baby, bronchial asthma or cardiac problem. B- length, Apgar score, and temperature. Inhalation anesthesia: Isoflurane. C- Also events observed were recorded Neuromuscular Blocking Agents (muscle including: birth time, cord cut, head relaxation) including succinylcholine and dried, body dried, placed on mother‟s atracurium. The analgesia consisted of abdomen, baby cry, and placed in open pethidine and fentanyl. 2-Spinal cot. anesthesia: included heavy bupivacaine Step 4: Observation of the mother- Clinical procedures: Step 1: infant pairs in the post partum ward: the Preparation of the staff: The staff 200 cases were randomly divided into including the obstetrician, neonatologist, one hundred mother infant pairs who anesthetist, nursing staff, and up to were subjected to the intervention of auxiliary workers were briefly informed breastfeeding support in th eperipartal about the aim of the study, and the period and included 50 NVD and 50 C.S. technique was thoroughly explained to The other one hundred mother infant them. Step 2: Observation of the mother pairs did not receive support by the in the perinatal ward: The research research worker in this period for worker greeted the mother and introduced comparison purposes. They included 50 himself to her, when the mother agreed to NVD and 50 C.S. comply with the research worker she was Peripartal support of the mothers was included in the study in the follow-up continued even after they left the labour study. An interview was conducted with ward and they were transported to the her using a predesigned questionnaire post partum maternity ward to make sure including: personal history: name, age, that they initiated breastfeeding with occupation, education, work status, correct positioning and attachment before smoking, intention to breastfeed and being discharged from the hospital. We experience, preference of the mode of observed and recorded the baby feeding delivery (NVD or C.S), knowledge about behavior (pre-feeding responses) as
43
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
reported by (7) and included the most and only 26 women (13%) were common responses documented as employed. Percent of women who follows: pushes feet down, grasping with achieved primary education in group 1 hands, hand to mouth, sucks fingers, was (16%), in group 2(14%), in group 3 sucks fist, pokes tongue out, licks, lip (14%) and in group 4 (14%). Percent of smacking, drooling saliva, attempts to women who achieved secondary turn head, turns head, attempt to lift head, education in group 1 was (46%), in group lifts head up, moves toward breast, 2(44%), in group 3 (42%) and in group 4 nudges breast with chin, begins to gape, (44%). wide gape, attempts to suck on skin, Percent of women who achieved tertiary attempt to grasp nipples, grasp nipples, education in group 1 was (26%), in group takes asymmetrical latch, suckles at 2(32%), in group 3 (32%) and in group 4 breast, sustained suckle, reattached, baby (28%). There were no statistical off breast. significant differences between the Support to mother infant pairs at groups as regard the level of education. discharge: The one hundred mother Co-morbidities showed no difference infant pairs subjected to breastfeeding between the NVD group and the C-S support at discharge included support and group except for anemia which was guidance in breastfeeding techniques, significantly higher among women of the adherence to exclusive breastfeeding and NVD group at (p value= 0.038), with 10 avoiding introduction of other milk or cases with history of anemia, 2 cases with foods, avoiding pacifiers, increasing history of heart problem, and 4 case with frequency of breastfeeding to maintain a history of hypertension, 4 case with a and increase milk supply, also history of diabetes in the NVD group, information was gathered about their while in women belonging to the C-S current breastfeeding practices, any group there were 4 cases with history of worries or anxieties they have this was anemia, 2 cases with history of bronchial done by using counseling skills. asthma, 2 cases with history of diabetes ■ Statistical analysis: and 4 case with a history of hypertension. The program used was SPSS version 16. Mean birth weight in male babies was Quantitative data were analyzed using (3364.26 + 472.6 gm) and (3265.56 mean and standard deviation, while +439.6 gm) in female babies (P = 0.128). frequency and percentage were used with Mean gestational age in male babies was qualitative data. Student t test and F test (38.82+ 1.08 weeks) in males and were used to compare means of different (38.72+1.21 weeks) in females groups, while Z test, Fischer exact test (P=0.569). and chi square to compare frequencies. The mean Apgar score at 1 and 5 minutes Results was significantly higher in NVD as Sociodemographic data of the studied compared to C-S babies. At 1 minute in population showed that 59 women NVD it was 7.4+ 1.46, and in C-S group (29.5%) were between 15-24 years, 115 it was 6.52+ 1.54 (P value = 0.001). women (62.5%) were between 25-34 Mean Apgar score at 5 min in NVD was years, 11 women (8%) more than 34 9.42+ 0. 64 and in C-S group it was 8.62+ years. Mean age of women included in 0.84 (P value = 0.001). the study was 27.3 years. The majority of Any initiation of breastfeeding was women 174 (87%) were not employed, performed by (80%) of group 1, (70%) of
44
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
group 2, (90%) of group 3 and (80%) of attempt to turn head; turns head and group 4 (P=0.1). attempt to lift head and "lifts head up". Timely initiation in the first hour The responses which were non occurred in 12.5% of group I; 8.6% of significantly influenced by GA included group 2; 28.9% of group 3; and 25% of moves toward breast; nudges breast with group 4. chin; begins to gape; wide gape; attempt Between first and second hour 15% of to suck on skin; attempt to grasp nipples; group I, 11.4% of group 2, 44.4% of grasp nipples; takes a symmetrical latch; group 3 and 42.5% of group 4 initiated baby suckles at breast; sustained suckle; their first suckle at the breast. There was reattached; and baby off breast finished a highly significant difference between feeding (Figure 2). the 4 groups as group 3 and group 4 Effect of mode of delivery on outcome initiated breastfeeding earlier than group of breastfeeding at discharge (in the 1 and group 2 (P value = 0.001) (Table supported group): even with support, (1). mothers undergoing NVD were more Pre-feeding responses: we identified 25 likely to exclusively breastfeed at pre-feeding responses. These were mostly discharge compared to C-S (P value= delayed in groups exposed to cesarean 0.02). While the C-S group were more section as shown by the mean time of likely to give supplements as milk appearance of pre-feeding responses. The formula, and glucose (P<0.001 and pre-feeding responses which were 0.075) as shown in table (2). significantly delayed included pushing feet down; grasping with hands; hand to Discussion mouth; sucks fingers; sucks fist; pokes tongue out; licks; lip smacking; drooling In this study we have identified the 25 saliva; attempt to turn head; turns head; responses in response to skin to skin attempt to lift head; lifts head up; moves contact after the first cry (7). Such toward breast; nudges breast with chin; responses have never been described begins to gape; wide gape; attempt to in a baby separated from the mother. suck on skin; Attempt to grasp nipples; However in our study we categorized grasp nipples; takes a symmetrical latch; reflexes that were linked to the brain baby suckles at breast; sustained suckle; stem as primitive and responses reattached and baby off breast finished feeding (P value= 0.001) (Figure 1). originating from the upper centers in Pre-feeding responses and gestational the brain as central responses. age (GA): Appearance of pre-feeding There were more significant delays responses was earlier with increasing GA. between the responses observed in the This finding was highly significant in 12 vaginal versus the cesarean in both responses, significant in one response and the brain stem (primitive) and the non significant in the remaining 12 central responses. However the delays responses. Pre-feeding responses that in the central group of responses were particularly delayed by decreasing which occurred mostly in the second GA included: pushing feet down; half of the first hour were much more grasping with hands; hand to mouth; sucks fingers; sucks fist; pokes tongue significantly delayed in those exposed out; licks; lip smacking; drooling saliva; to cesarean delivery, indicating that probably anesthesia and the stress of 45
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
operative procedures blocked these the auditory by the sound, these bring responses and prevented their timely about stimulation of the remaining appearance (8). Moreover interruption cranial nerves including the 4th ,5th of the mother infant contact as when and 6th cranial nerves(for eye moved out of the operating theater to movements), facial nerve (for rooting her ward, resulted in a further delay in reflexes), trigeminal nerve the completion of the appearance of (mouthing, lip evertion, and suckling these responses for up to three or movements), lingual nerve (for more hours especially in the mothers smacking and salivating, tongue exposed to cesarean delivery and protrusion and licking responses) and anesthesia (9,10). finally 9th and 10th cranial nerves The initial cry is a reflex initiated for (for swallowing). By grouping each air entry into the lungs, hence it is not together we were able to identify the a cry in the sense of expression of pattern by which the brain stem is need but rather a reflex induced by able to adapt to the external expansion of the perfused lung. environment(3). Tactile stimulation of the back may Critical period is defined as windows stimulate this reflex if baby is too of opportunity in early life when a weak to initiate the first cry. Whereas child‟s brain is exquisitely primed to perfusion of their brain results in receive sensory input in order to stimulation of peripheral reflexes develop more advanced neural involved the flexor muscles of the systems. This follows the first rule of legs and arms and hands. Again such neuroscience: "Cells which Fire movements do not begin except after together, Wire together, And those sufficient contact through skin to skin which don't, won‟t" and the second with the mother or other. The rule of neuroscience: "Use it, or lose massaging movements caused by the it" (11). Skin-to-skin contact (SSC) crawling movements and mother's fires and wires the amygdale- instinctively activated maternal prefrontal-orbital cortical pathway response of rubbing her baby's back which is the first and essential part of will stimulate the arousal (in the an efficiently regulated and organized reticular formation of the brain stem) right brain. and causing what Widstrom termed as In early postnatal life, maintenance of the "familiarization reflexes". These critical levels of tactile input is reflexes are located in the brain stem important for normal brain close to the respiratory center and maturation. The next pathway awakening centers in the mid brain requires eye-to-eye contact. This is and hence their early appearance. the basis of healthy right brain Whereas responses involving the development. The wiring of the cranial nerves are brought about by brain‟s pathways is best supported stimulation of these nerves, olfactory when it can integrate quality sensory by smell, the optic by vision eye, and input through several pathways at
46
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
once, particularly during critical disengages the brain to conserve periods of development (12). energies and foster survival by the Difficulties elicited with initiating risky posture of feigning death (14). breastfeeding are simply due to the Operative procedures followed by failure to of the care taker to realize early mother-infant separation induce that mothers and babies need to adapt stress to the mother. Stress hormone- and be familiarized to one another boost occurs when signals arise from before initiating the suckling at the the hypothalamus and pituitary gland breast process. stimulate the adrenal gland to pump Through “hidden maternal out high levels of stress hormones regulators”, a mother precisely "cortisol". The body's sympathetic controls every element of her infant's nervous system, responsible for heart physiology, from its heart rate to its rate and breathing, shifts into release of hormones from its appetite overdrive. The heart beats faster, to the intensity of its activity, forming blood pressure rises and the lungs a kind of invisible hot house hyperventilate. Sweat increases and "Habitat" (13). even the nerve endings on the skin Separation is life threatening for the tingle into action, creating goose human newborn. It is the habitat bumps. The brain stops thinking which determines which brain about things that bring pleasure, program is operating, which then shifting its focus instead to determines the behavior. When the identifying potential dangers. To newborn is separated from its mother, ensure that no energy is wasted on it experiences protest: the baby shows digestion, the body will sometimes intense activity, trying to find its respond by empting the digestive tract habitat, followed by despair response: through involuntary vomiting, when separation is prolonged, system urination or defecation (15). shuts down for prolonged survival All these can be allied by SSC then protest-despair or also called tranquilizing effects. SSC needs to hyper arousal-dissociation which is a take place early and for a long enough hypermetabolic state in which the duration of at least 2 hours of sympathetic nervous system (SNS) is uninterrupted continuous skin to skin activated, increasing heart rate, contact in order to be complete. Early respiratory rate, blood pressure and adverse experiences result in an tone. This sequence of distress is increased sensitivity to the effects of expressed first in crying, then stress later in life, and render an screaming, then fear and terror. individual vulnerable to stress related Dissociation is a hypo metabolic state psychiatric disorders. Origins of that develops later by activating the many behavioral deviations are parasympathetic nervous system unknown; child neglect, abuse, (PSNS), state of “conservation- abnormal shyness, attention withdrawal” in which individual
47
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
deficiencies, hyperactivity, colic, the mother. Arch Dis Child Fetal sleep disorders (16). Neonatal Ed. 90, F500-F504. 2- Kroeger, M., and Smith, L. (2004) The damage caused by separation is Impact of birthing practices on "massive and past the point of repair” breastfeeding: Protecting the and our current birth practices are mother and baby continuum. psychologically crippling to babies, Boston: Jones and Bartlett. mothers, and society as a whole (17). 3- Christensson K, Cabrera T, Christensson E, Uvnas-Moberg K, This is even more so when mothers Winberg J.(1995) Separation are exposed to operative delivery distress call in the human neonate in especially cesarean delivery, where the absence of maternal body complications at birth, to both mother contact. Acta Paediatr. 1995; 84:468-473. and baby, are more likely to occur, 4- Ginosar Y, Russel IF and Halpern resulting in early separation and delay SH (2005). Is regional anesthesia of the first contact and first breastfeed safer than general anesthesia for (17,18,19). cesarean section? In: Halpern SH, Klaus and Kennel (20) have called the Douglas MJ, editors. Evidence- based Obstetric Anesthesia. Oxford: first minutes, hours and days of life as Blackwell; 2005:108-31. the „sensitive period‟ for parent-infant 5- Bricker L and Lavender T (2002). contact as it may influence parent‟s Parenteral opioids for labor pain behavior with their infant later in life. relief: a systematic review. Am J Obstet Gynecol 2002; 186: S94-109. More research is required to unravel 6- Sikorski J, Renfrew MJ (2004). the mystical significance of the pre- Support for breastfeeding mothers. feeding reflexes that may increase our Cochrane Database Syst Rev. 2004 understanding of child development ;( 4):CD001141 and successful breastfeeding. 7- Cantrill, R. (2006): Influence of naked body contact between mother Our study shows that medicalization and newborn on effective of birth that has replaced natural breastfeeding, Griffith University, childbirth by the use of anesthesia Australia. impedes nature and changes the way 8- Nissen E, Lilga G, Ransjo- Arvidsson A-B, Matthiesen A-S, humans come into life and thereby Uvnasmoberg K, Widstrom A- has influenced breastfeeding success M(1995). Effects of maternal leading to early cessation and early pethidine on infants developing introduction of supplements and breastfeeding behavior, Acta weaning foods. Supporting mothers at Paediatr Scand 1995; 84: 140-5. 9- Widstrom A-M, Ransjo-Arvidsson risk can improve breastfeeding A-B, Christensson K, Matthiesen A- outcomes and decrease suboptimal S, Winberg J, Uvnasmoberg K feeding practices that expose the baby (1987). Gastric suction in healthy to morbidity and mortality (21). newborn infants, Acta Paediatr Scand 1987; 76: 566-72. References 10- Wittels B, Glosten B, Faure EA, et 1- Fransson, A., Karlsson, H., and al (1997). Post caesarean analgesia Nilsson, K. (2005) Temperature with both epidural morphine and variation in newborn babies: intravenous patient controlled Importance of physical contact with analgesia: neurobehavioral 48
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
outcomes amongst nursing neonates. 17- Pérez-Escamilla R, Maulen- Anesthesia and Analgesia 1997; 85: Radovan I, Dewey K. (1996). The 600–6. association between cesarean 11- Schatz C. The Developing Brain. delivery and breast-feeding Scientific American 1992; outcomes among Mexican women. 267(3):60-7. Am J Public Health. 1996; 86:832- 12- Mccain MN and Mustard JF. (1999) 836. Reversing the Real Brain Drain: 18- Pérez-Ríos Naydi, Gilberto Ramos- Early Years Study Final Report. Valencia and Ana Patricia Ortiz 1075 Bay street, Toronto ON M7A (2008) Cesarean Delivery as a 1E9: Ontario Children's Secretariat. Barrier for Breastfeeding Initiation: 13- Gallagher W. (1992) Motherless The Puerto Rican Experience J Hum Child. The Sciences pp:12-5. Lact 2008 24: 293. 14- Schore AN.(2001) The effects of 19- Porreco, R.P. and Thorp, J.A. early relational trauma on right brain (1996): The cesarean birth epidemic: development, affect regulation, and Trend, causes, and solution. Am J infant mental health. Infant Mental Obstet Gynecol; 175: 369-74. Health Journal. 22, 201-269. 20- Klaus MH, Kennel JH. (2001) Care 15- Kjellmer I, Winberg J. (1994) The of the parents in 'Care of the high- neurobiology of infant-parent risk neonate', 5th edition, W. B. interaction in the newborn: an Saunder's Company. 195-222. introduction. Acta Paediatr Suppl. 21- Philipp, B.L. and Mere wood, A. 397:1-2. (2004): The baby friendly way: The 16- Pearce JC (1992). Evolution‟s End: best breast feeding start. Pediatr Claiming the Potential of Our Clin N Am 51:761-783. Intelligence. San Francisco: Harper San Francisco, 1992; p 115.
49
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Table (1): Comparing frequency distribution of breastfeeding initation and time to time to first breastfeed in mother-infant groups exposed to early skin to skin contact: Breastfeeding G I G II G III G IV initiation Yes 40(80%) 35(70%) 45(90%) 40(80%) Initiated No 10(20%) 15(30%) 5(10%) 10(20%) Breastfeeding X2 test 6.25 P value 0.10 NS <1H 5(12.5%) 3(8.6%) 13(28.9%) 10(25%) 1-2H 6(15.0%) 4(11.4%) 20(44.4%) 17(42.5%) Time to 1ST day 29(72.5%) 28(80.0%) 12(26.7%) 13(32.5%) breastfed from Fischer delivery exact 35.72 test P value 0.001 hs
Table (2): Comparison of the outcome of breastfeeding in the supported groups (group 1 and group 3) by mode of delivery at discharge
CS(G I) NVD(G III) Total Z At discharge (50) (50) P value test No % No % No
Breastfeeding 35 41.2% 50 58.8 85 1.65 0.049 Exclusive BF 15 35.7 27 64.3 42 1.93 0.0267 BF + Artificial formula 7 70.0 3 30.0 10 3.24 0.001 BF + Honey 1 25.0 3 75.0 4 1.16 0.124 BF + Water 2 50.0 2 50.0 4 0.0 0.5 BF + Glucose 30 60.0 20 40.0 50 1.44 0.075 BF, Breastfeeding; CS= Cesarean section; NVD=Normal vaginal delivery; P< 0.05= significant; P< 0.01 highly significant; P> 0.05= non significant.
50
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
350 300 250 200 150 100 NVD(G III+G IV) 50 CS(G I+G II)
0
Licks
Sucks fist Sucks
Widegape
Reattached
Turns head Turns
Lip smacking Lip
Lifts headup Lifts
Sucks fingers Sucks
Grasp nipples Grasp
Begins to to Begins gape
Drooling saliva Drooling
Hand to mouth Handto
Sustained suckle
Pokes out Pokes tongue
Pushes feet Pushes down feet
Attempt to lift head lift Attempt to
Grasping with with hands Grasping
Moves towardbreast Moves
Attempt head turn Attempt to
Baby suckles at breast atsuckles Baby
Attempt onskinsuck Attempt to
Nudges breast with with chin breast Nudges
Attempt nipples grasp Attempt to Takes asymmetrical latch Takesasymmetrical Baby off breast finish feeding off Baby finish breast Figure (1) Mean time (in minutes) of appearance of pre-feeding responses according to mode of delivery (vaginal versus cesarean delivery) among the mother-newborn pairs exposed to skin-to-skin in the postpartum period.
350
300
250
200
150 100 (39-40) weeks 50 (37-38) weeks
0
Licks
Sucks fist Sucks
Wide gape Wide
Reattached
Lip smacking Lip
Lifts headup Lifts
Sucks fingers Sucks
Grasp nipples Grasp
Begins to to Begins gape
Drooling saliva Drooling
Handto mouth
Sustained Sustained suckle
Turns to lift to head Turns lift
Pokes out Pokes tongue
Pushes feet Pushes down feet
Attempt relatch Attempt to
Attempt tolift head
Grasping with with hands Grasping
Attempt head turn Attempt to
Baby suckles ofbreast suckles Baby
Moves towards towards breast Moves
Attempt onskinsuck Attempt to
Nudges breast with with chin breast Nudges
Repeatedsuck attempts
Attempt nipples grasp Attempt to Takes asymmetrical latch Takesasymmetrical Baby off breast finish feeding off Baby finish breast Figure (2) Mean time in minutes of appearance of pre-feeding responses by gestational age (39-40 weeks versus 37 to 38 weeks) among the mother-newborn pairs exposed to skin-to-skin in the postpartum period.
51
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
جعطٞو ٍْعنسبت اىحغزٝة اى٘ىٞذٝة فٜ اى٘الدة اىقٞصشٝة جإثش عيٚ ٍَبسسبت اىشظبعة اىطثٞعٞة عْذ اىخشٗج ٍِ اىَسحشفٚ زألعؽسر زٌذوٛؽس/ ِىغٓ خ١شٞ* ، زٌذوٛؽسظ/ دعسء زٌشفسعٟ** ، زٌذوٛؽس/ ِىّذ عطذ زٌفؽسن زٌغ١ذ*** ، زألعؽسرظ زٌذوٛؽسظ/ عضظ أضٛ زٌفعً** **قسٌ اىْسبء ٗاىح٘ىٞذ ميٞة غب بْٖب** قسٌ غب األغفبه ميٞة اىطب بْٖب- خبٍعة بْٖب *** ٗصاسة اىصسةٗاىسنبُ ______
اىخيفٞة: ِسصزي ٕ٘سن غّٛض وٛي ز١ٌ٢دسغ زؽٌدؼ ٟدثـش عٍدٝ زٌّٕةىغدسغ زٌةصدط١ع زؽٌدٛؽؼ ٌٟدذ عٕدذ زٌٛيدظ ٟٙؽٕؼٚ ضفسعٍع زؽٌشزضػ زٌةسغفٟ ض١ٓ زألَ ١ٌٚٚذ٘س ، ؼٚةذ غش٠مع زٌٛيدظ ٛٔٚع ِٓ زؽٌخدذ٠ش زٌزٞ ٠ةطٝ ٌألَ عٕذ زٌٛيدظ ٛٔٚع زٌذعُ زؽؼ ٟؽٌةشض ٌٗ زٌٛزٌذظ ِٓ زٌةٛزِدً زؽٌدٟ لدذ ؼدثـش عٍدٝ زٌطذز٠ع زٌّطىشظ ٚزٌٕسلىع ضسٌشظسعع زٌطط١ة١ع ٚزإلعؽّشزس ضٙس. زٌٙذف: ؼم١١ُ ؼأـ١ش ٚغش٠مع زٌٛيدظ عٛؼ ٍٝلػ١ زٌطذء ضسٌشظسعع ؼٚدأـش سدٚد زٌفةدً زؽٌغز٠دع زٌمط١ٍدع عٍٝ ٔمسن ِّسسعع زٌشظسعع زٌطط١ة١ع. غشق زٌطىٝ٘ :ؿ دسزعع ٚصف١ع ِمطة١ع ؼعّٓ 011 عد١ذظ ؼةشظدػ ٌٍدٛيدظ زٌطط١ة١دع ٚ 011 عدد١ذظ ٌة١ٍّددسغ ل١صددش٠ع ضسعددؽخذزَ زؽٌخددذ٠ش زٌكددٛوٟ عددٓ غش٠ددك ضٛض١فسوددسذ١ٓ ِىفدد . ٚلددذٌٙ ػِددُ ِّسسعع زٌالِغدع ضسٌمٍدذ جٌدٝ زٌمٍدذ عٕدذ زٌدٛيدظ ؼٚدُ ِالوادع زعدؽمسضسغ لطدً زٌشظدسعع ؼٚغدم١ً ٚلددػ وٛٙس٘ددس فددٟ وددال ِددٓ زٌّمّددٛع١ؽٓ. ؼ ٚددُ جخ١ؽددسس 01 أَ ضددٛيدظ غط١ة١ددع ٚ 01 أَ ٚغفددً ؼةشظٛز ٌٍٛيدظ زٌم١صش٠ع ؼ ُؼٚمذ٠ُ ٌُٙ زٌذعُ عٕذ زٌٛيدظ. اىْحبئح: ودسْ ٕ٘دسن ؼدأخش ٍِىدٛو فدٟ زٌطدذء زٌّطىدش فدٟ زٌغدسعع زألٌٚدٝ ضسٌشظدسعع زٌطط١ة١دع فدٟ وسيغ زٌة١ٍّع زٌم١صش٠ع زؼ ٟؽٌةشظؽٌٍ ػخذ٠ش زٌكدٛوٚ ِٟةاّٙدس فدٟ زٌّمّٛعدع غ١دش زٌّذعّدع )6.8٪( ضسٌّمسسٔع جٌٝ ِمّٛعع زٌٛيدظ زٌطط١ة١ع زؼ ٟؽٌةشظػ ٌٍذعُ )ٚ .)٪86لذ ٌٛوظ ؼأخشفٟ زٌّٕةىغسغ زٌةصط١ع زٌمط١ٍع ٌٍشظسعع فٟ زٌّمّٛعدع زؽٌدؼ ٟةشظدؽٌٍ ػخدذ٠ش ٚ زٌة١ٍّدع زٌم١صدش٠ع ٚفٙٔ ٟس٠ع زؽٌم١١ُ عٕذ 3 أشٙش ٚلدذٔس أْ ٔغدطع زٌشظدسعع زٌطط١ة١دع ؼدأـشغ ضسٌدذعُ ٚٚصدػٍ ٪81 ِمسضً 50٪ فٟ زألِٙسغ زؽؼ ٌُ ٟؽٌةشض ٌٍذعُ . زىخالصة:جْ زٌة١ٍّع زٌم١صش٠ع ؼةطً زٌطذء زٌّطىش ضسٌشظسعع عٓ غش٠ك ؼأخ١ش زٌّٕةىغسغ زٌمط١ٍع ٌٍشظسعع أدغ ِّس ٠ثـش عٍٝ ٔمسن زٌشظسعع ٌٚزٌه ٠مص ؼكم١ع زٌّّسسزعسغ زٌصذ٠مع ٌألَ ؽٌٍم١ًٍ ِٓ زٌٛيدزغ زٌم١صش٠ع. . ______
52
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Challenges Facing the “Updated Baby Friendly Hospital” Program in a Maternity Hospital in Alexandria Ahmed Fawzi MD*, Hala Kadry PHD**, Salah Abd Rabo MD*, Azza Abul-Fadl MD*** *Obstetric department, Alexandria faculty of medicine, Alexandria University **Family Health department, High Institute of Public Health, Alexandria University, ***Pediatric department, Benha faculty of medicine, Benha University ______Abstract Introduction: The Baby Friendly Hospital Initiative (BFHI) is a global program that has been recently updated and expanded to include mother friendly practices and the "first hour skin to skin”of step 4 of the “Ten steps” for initiating the first breastfeed. Aim: To assess the current status of implementation of the Ten Steps of BFHI and the mother friendly practices. Methodology: This study was carried out 18 months following implementation of the UNICEF/WHO 20 hour training course in the Baby Friendly Hospitals of over one half of the staff in the maternity and pediatric units and a course for Mother Friendly devised by the Alexandria Women Health Center. A sample of 30 mothers were interviewed from each of the service units of the obstetric antenatal, postnatal normal vaginal birth, postnatal cesarean section (C-S) deliveries and neonatal intensive care units (NICUs), with a total of 120 mothers in a period of 2 weeks in December of 2012. The assessment was carried out by local residents under the supervision of the head of department. Findings: Education about mother friendly practices was highest (87.3%) while education about early initiation of breastfeeding through early extended one hour skin to skin (STS) was lowest (0%). Initiation of breastfeeding during the first hour was high but mostly without STS (73%). Teaching mothers how to breastfeed was also high (73.3%), but remaining practices were low, particularly early separation and supplementation with fluids (30%) and milks (66.7%). Company representative were allowed to contact mothers (33.3%). NICU practices encouraged milk expression in 16.7%, and mother to hold her baby STS in 23.5%. Conclusions: Overall practices were low and indicate the importance of the presence of an installed in-service training program or monitoring system to ensure sustainability of the program inputs. ______Introduction been designated as Baby Friendly (1,2). The World Health Organization The main aim of the Baby Friendly is WHO/UNICEF Baby-Friendly to reduce neonatal and infant mortality Hospital Initiative (BFHI) was and long term disabilities from chronic developed to support the disease by increasing the rates of early implementation of the Ten Steps for initiation with continued exclusive Successful Breastfeeding. Since it has breastfeeding whilst protecting been launched in 1991, over 20,000 mothers and babies from suboptimal facilities caring for babies at birth have feeding practices and exposure to 53
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
infant milk formula. The increasing Since the designation of over 125 hazards associated with the latter have Baby Friendly hospitals and health been well documented and it goes centers in 1995 in Egypt, the BFHI has beyond doubt that depriving infant of come to an agonizing standstill. This mother's milk and exposure to other has influenced hospital and birth milks in the critical period of growth practices and has caused the neonatal and development early in infancy is mortality rates and case morbidity hazardous to their short and long term rates to also likewise come to a health and well being as well as their standstill. Although substantial survival(3). improvements in child health have The practices included there in the been achieved, the critical period of Baby friendly have been supported by neonatal health remains to be the evidence to lead to successful challenge that faces the country and breastfeeding continuation. These may be indirectly responsible for the begin with educating women during increasing rates of non communicable pregnancy about the benefits and disease in the country (5). management of breastfeeding (step 4), Attempts at making hospitals practices also encouraging mother friendly Baby Friendly have faced many practices at birth. The practice that has challenges, the most important of been updated in 2006 is to support which is sustainability and lack of initiation of breastfeeding as early as integration between services, i.e. immediately after birth by immediate obstetric, neonatal and pediatric continuous uninterrupted skin to skin services, as hospital and primary contact for one hour during which the health care practices (6). The aim of the first breastfeed occurs, whilst teaching current study is to examine the extent mother baby's readiness to feed (step of adherence of the maternity and 4). Next in the postpartum ward, neonatal services providers to the Ten teaching mothers how to breastfeed steps one year following an intensive and how to express their milk if they training program for over one half of are separated from their babies (step 5) the staff using the UNICEF/WHO 20 and ensuring that no other hour course for promoting supplements are introduced other than breastfeeding in a Baby Friendly breastmilk (step 6), keeping the Hospital. mother and baby together in one room The aim of this baseline assessment is (step 7) and encouraging unrestricted to evaluate implementation strategies breastfeeds with no restriction on of BFHI in our country and to identify frequency or duration (step 8). Finally the main barriers to improved ensuring the baby is not offered any practices that abide with BFHI global bottles or pacifiers (step 9) and criteria. This will assist other hospitals referring her on discharge to an in the country meet the Global Criteria appropriate mother support group for of the Baby Friendly Hospitals for continued breastfeeding (step 10) (4). designation and identify a national
54
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
strategy for improved implementation. 1- Pregnant women in the antenatal care It will also assist the current hospital to clinics: the 30 women were selected boost its accreditation status as randomly and assessed practices ElShatby is one of the leading teaching related to receiving information hospitals and university institutions in (verbal or written or posted) about the country. importance of breastfeeding, early Subjects and Methods skin to skin contact (STS) with her This is a cross sectional descriptive baby for one hour immediately baseline monitoring survey for assessing after birth practices of health staff working in three 2- Mothers in the postnatal ward separate service units in ElShatby delivered by vaginal the 30 University Maternity Hospital in the mothers were interviewed period of December 2012, following the regarding antenatal education and implementation of training in the Ten perinatal mother friendly practices steps in the past 18 months. as well as postnatal practices that Logistics: approvals to carry out the study involve early and prolonged STS in the ElShatby University hospitals were between mother and baby, early obtained by official letters from the Mother and Child Friendly care initiation of breastfeeding through association (MCFC) regarding the MoH first hour STS contact between and UNICEF Egypt office funded mother and baby, rooming-in and assistance to support implementation of on-demand feeding, exclusive the BFHI in the ElShatby hospital. As a breastfeeding, no use of bottles and result MCFC trained over 250 staff pacifiers. working in the maternity, neonatal 3- Mothers delivered by cesarean intensive care unit (NICU) and pediatrics section: the 30 mothers were university hospitals through the interviewed about whether they "UNICEF/WHO twenty hour course for were encouraged to have a spinal or promoting breastfeeding in baby friendly hospitals". Hospital policy was drafted epidural anesthesia rather than and disseminated to all staff. It was posted general anesthesia, the hazards of in the pediatric department but not yet in having an elective cesarean the maternity hospital pending approval delivery and whether there was a by the quality department. medical indication for their section The study targeted a total of 120 mothers delivery. (30 pregnant women, 30 delivered by 4- Mothers whose babies attend in the normal vaginal delivery, 30 delivered by NICU: the 30 mothers were cesarean section and 30 with babies in the interviewed about whether they NICU. Informed consents were obtained were encouraged/allowed to be from the participants for their inclusion in the study. admitted to the hospital, whether The study included four sets of they were encouraged to care for questionnaires targeting the following their baby by STS care. Also subjects: whether they were instructed to empty their breasts 6-8 times in 24
55
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
hours to maintain milk flow and had it done early and 5 mothers did it late, production, whether they were so that 23 out of the 30 mothers delivered encouraged to feed their baby by by vaginal delivery did not practice it all. cup and spoon. Figure 2 compares frequency distribution Compilation and analysis of data: the of practices related to timely initiation of data was compiled in collective sheets and breastfeeding within the first hour, only 6 were analyzed by frequency distribution (20%) initiated breastfeeding within the (percent) and presented in tables to first hour through STS, while 22 (73.3%) represent the practices covering the global initiated breastfeeding early without STS criteria for each of the Ten steps of the and 14 (46.7%) initiated breastfeeding Baby friendly and mother friendly late and without STS. practices in addition to abidance to the Steps 5, 6, 7, 8 and 9: This is shown in International Code of Marketing of breast figure (3) where distribution of practices milk substitutes (ICMBMS) code and related to the success of Step 5, step 7 and ending free and low cost supplies of infant step 8 of the Baby Friendly Hospital regarding teaching mothers breastfeeding milk formula . techniques of how to breastfeed was Results described by 22 out of 30 (73.3%), breast The results are presented in table 1 and milk expression by 10 out of the 30 figures 1 to 5. They were analyzed in (33.3%), encouraging rooming in (no accordance to the UNICEF/WHO Baby early mother-infant separation) by 13 out Friendly Hospital global criteria for the of 30 mothers (43.3%) and on-demand Ten steps and the Expanded Integrated feeding with no restriction on feeding Baby Friendly Hospital Update for the frequency or duration by 15 mothers steps from 3 to 10, mother friendly and (50%). Figure 4 shows the distribution of adherence to the ICMBMS as follows: practices related to the success of Step 6 Step 3: This is shown in table (1) that and 9 of the Baby Friendly Hospital Fluids compares exposure to education among were introduced to 9 (30%) and other the mothers who were interviewed in the milks were introduced to 20 (66.73%) to perinatal versus those who interviewed in breastfed without a clear medical the antenatal care (ANC) clinics. Those indication and pacifiers were offered in 14 pregnant women who received (46.7%), while encouraging feeding by information about mother and baby cup or spoon was reported by 4 mothers breastfeeding practices in the perinatal (13.3%). period were significantly higher than those Global practices related to Expanded interviewed in the antenatal clinics. The Updated BFHI: figure 5 shows that importance of early skin to skin (STS) distribution of Mother Friendly practices contact was poor in both while mother (related to encouraging light food and friendly practices were highest in total. drinks to mothers early in labour was Step 4: Figure (1) shows that the reported by 20 (66.7%), movement, frequency distribution of practices related mother's knowledge that cesarean sections to the success of Step 4 in the Baby were carried out according to a medical Friendly Hospital regarding first hour indication was reported by 10 (33.3%) STS. Early and prolonged STS were very mothers. Spinal anesthesia in c-section low (6% and 3% respectively). Most of the was reported to be encouraged by 16 mothers in the delivery ward were not mothers (56.7%). Mothers who were exposed to STS by staff as only 2 mothers 56
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
informed of hazards associated with C- The continued growth may reflect the section were 10 (33.3%). Abidance to the dedication of ministries of health and International code of marketing breast national BFHI groups, as well as milk substitutes, assessed by asking increasing recognition that the Ten mothers whether they were exposed to an Steps are effective quality infant milk formula company representative who offered them gifts or improvement practices that increase free samples was 10 (33.3%). Referral of breastfeeding and synergize with mothers at discharge to a breastfeeding community interventions and other (1,2) specialists was reported by 6 (20%) of program efforts . mothers in postpartum ward. In Egypt the exclusive breastfeeding Neonatal Intensive Care unit practices: rates in hospitals and early initiation distribution of mothers who reported they rates have been reported by the were encouraged and supported express national demographic health survey as their milk 6-8 times per day was 5 (16.7%) being in the range of 40-50% (6). This and feed expressed breast milk by cup or also reflects on exclusive spoon (6.7%). While mothers who were encouraged to stay with their baby 3 breastfeeding rates at 6 months which mothers (10%) and mothers encouraged to is around 50%. While a study in practice STS was 7 (23.35%). Switzerland that studied hospital Discussion practices that influence the duration of The UNICEF/WHO Baby Friendly breastfeeding workers showed that if a Hospital Initiative (BFHI) is an child had been exclusively breastfed in undisputed way to reduce infant the hospital, the median duration of mortality and improve quality of care exclusive, full, and any breastfeeding for mothers and children. The BFHI was considerably longer than the mean has had great impact on breastfeeding for the entire population or for those practices. Rates of increase in the who had received water-based liquids number of ever-certified "Baby- or supplements in the hospital. A Friendly hospitals” vary by region and positive effect on breastfeeding show some chronological correlation duration could be shown for full with trends in breastfeeding rates (1). rooming in, first suckling within 1 Breastfeeding support in peripartal hour, breastfeeding on demand, and period by implementing Ten Steps also the much-debated practice of implementation and abiding by the pacifier use (10). code has been shown to improve child The current study we have noted that health and decrease maternal and Baby Friendly practices in ElShatby infant morbidity and mortality hospital are experiencing many particularly in low income countries challenges, the most striking is the (7). Mother friendly practices have a poor implementation of the STS care, similar effect, and support of these exclusive breastfeeding and other latter practices can significantly steps related to education prenatally increase breastfeeding rates as shown and teaching mothers techniques and by other workers in Egypt (8,9). skills in breastfeeding.
57
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
However in a similar survey carried In Russia a study carried out in Baby out 4 years ago in the same hospital, Friendly hospitals (BFHs) showed that early initiation of breastfeeding there were some shortcomings as the through STS practice was very low. frequent use of labor anesthesia; early However implementation in public skin to skin contact, rooming-in, and hospitals was better than university initiating breastfeeding immediately; hospitals at that time. However this and a short length of "skin-to-skin" study shows that there has been some contact (<30 minutes). The women in improvement but not to a great extent. BFHs also observed the use of feeding The reason for the low rates despite the bottles and dummies, and experienced extensive training carried out is some problems with breast health. probably related to the absent of They attributed this to the lack of refresher trainings after training, since attention to maintaining adherence to the former was carried out 18 months the criteria of the 10 steps of the Baby- after the end of the last training. The Friendly Hospital Initiative (11). underlying causes of poor abidance by The attitude towards Baby Friendly practices may be due to turn over of Hospitals concepts is particularly staff, lack of staff commitment, lack of important and unless maternity staff in placed systems that make Baby members were really convinced of its Friendly practices work or simply the importance it may not be sustained. In lack of motivated staff or manner of Australia despite strong support for implementation meaning the lack of BFHI, the principles of this global continuous follow-up interventions for strategy are interpreted differently by ensuring sustainability (7,8). health professionals and further Zakarija-Grkovic et al.,(4) followed up education and accurate information is the outcome of babies who were required. It may be that the current delivered in a hospitals exposed to the processes used to disseminate and 20 hour course, they noted that implement BFHI need to be reviewed. practices did improve for early The findings suggest that there is a initiation, exclusive breastfeeding, contradiction between the broad rooming in and demand feeding. The philosophical stance and best practice improvement for exclusive approach of this global strategy and breastfeeding at discharge was from the tendency for health professionals 6% to 11% over the 12 months of the to focus on the Ten steps as a set of period of the study. This improvement tasks or a checklist to be accomplished although significant does not really (12). reflect effectiveness of training alone In our implementation of Baby in improving baby friendly practices Friendly most of the training in the and that more effective interventions maternity hospital was carried out by need to be done to ensure a change in nurses, while most of the training in practices. the pediatric hospital was carried out for pediatric medical staff. Although
58
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
nurses are fully committed to the WHO/UNICEF Baby Friendly practices they learnt as shown by the Hospital Initiative (BFHI). improvement in techniques and Representatives from seventy six practices that do not involve policies. hospitals responded to a telephone However practices mostly carried out survey relating to hospital under supervision of the medical staff breastfeeding practices and policies as included first hour skin to skin and defined by BFHI's Ten Steps to allowing mothers inside NICUs or Successful Breastfeeding. No hospital prescribing supplements, showed no fully supported the Ten Steps. improvement. This strongly indicates Compliance with the WHO/UNICEF the importance of involving more of criteria varied greatly. The least the medical staff as decision makers in support was for Step 1, only 28% of clinical practice to facilitate the work hospitals had a written breastfeeding of nursing staff in supporting policy that was communicated to all breastfeeding. Other workers have staff. The greatest support was for Step shown that show that nurses who had 3, 93% of hospitals had staff who participate in the BFHI training informed all pregnant women of workshop are significantly more breastfeeding benefits. They knowledgeable about some aspects of concluded that in order to increase exclusive breastfeeding, they had breastfeeding rates and duration, more positive attitudes and were more administrators of hospitals that offer likely to employ correct practices for maternity services must be the promotion of exclusive consistently hammered with the breastfeeding (13). However their concepts and importance of the Ten practices need to be supported and Steps, in order to create a encouraged by medical staff. breastfeeding supportive culture The use of the decision makers course within their institutions (14). for medical staff can allow them to Walsh et al., (15) reported in their study become more committed to the BFH, of BFHs that staffs' understanding and rather than enroll them in a 20 hour personal views are often discordant course that requires time and which with BFHI aims. Perceived difficulties they cannot be committed to complete. include the accreditation process, This could be a future strategy for hospital dynamics, and the Ten Steps sustaining Baby Friendly in hospitals, implementation plus a bottle feeding where medical staff can receive the culture and maternal employment that one day decision-makers course and impact upon continued breastfeeding. the nursing staff who are in direct They concluded that Upper contact with mothers can receive the management support, specific 20 hour course. funding, a dedicated coordinator with In the USA, all Missouri hospitals that "area leaders", development of a offer maternity services were assessed specific breastfeeding policy to measure their compliance with incorporating various disciplines and
59
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
staff, containing detailed protocols targeted in the Ten steps to successful that comply with the International breastfeeding. From a public health Code of Marketing of Breast Milk perspective, we may influence the Substitutes and subsequent World duration of breastfeeding through Health Assembly (WHA) resolutions, better post-discharge support services, are all required. Staff and mothers or through interventions that improve require multiple modes of education to attitudes to breastfeeding in specific understand the BFHI, including socio-cultural and economic groups sponsorship for training of lactation (23,24). The fostering of mother support consultants (15). groups by the facility can have a In a recent study workers significant effect on the successful recommended a tool for measuring continuation of breastfeeding i.e. compliance to BFHI and concluded duration and exclusiveness of that a methodology to measure BFHI breastfeeding (25). compliance may help support the Conclusion: implementation of this effective With renewed interest in intervention and contribute to maternal/neonatal health, improved maternal and child health(16). revitalization of support for Ten Steps In Egypt, a pilot monitoring tool for and their effective institutionalization measuring compliance to the global in maternity practices should be criteria of the Ten steps BFHI within reconsidered. The BFHI provides a hospitals showed that such tools can framework for addressing the major motivate staff to improve their factors that have contributed to the performance and sustain it as it erosion of breastfeeding, with a focus becomes routine practice rather than on maternity care practices that implementing one time training interfere with breastfeeding. Until without any follow-up system, practices improve, attempts to especially in hospitals that do not have promote breastfeeding outside the an in-service training policy or system health service will be impeded. installed in place (17). Other workers Installment of in-service training have shown the importance of programs in all hospitals particularly administrator's commitment, in- university and public hospitals in the service training programs and country is a real need that can prove installment of monitoring systems and beneficial for improving, updating integration into quality management knowledge and practice of staff, as influenced the success of BFHI impact well a cost effective intervention for on the community (18-22). Moreover reducing morbidity, mortality and other workers have shown that socio- expenditure on health care services. demographic and cultural factors may References be more important determinants of the 1- Labbok MH. (2012) Global baby-friendly duration of breastfeeding than some of hospital initiative monitoring data: update and discussion. Breastfeed Med.7:210-22. the very specific hospital practices
60
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
2- Goodman K, DiFrisco E. (2012) Achieving attitudes and practices regarding exclusive baby-friendly designation: step-by-step.MCN breastfeeding. Afr J Med Med Sci. 31(2):137- Am J Matern Child Nurs. 37(3):146-52. 40. 3- Saadeh RJ. (2012) The Baby-Friendly Hospital 14- Syler GP, Sarvela P, Welshimer K, Anderson Initiative 20 years on: facts, progress, and the SL (1997) A descriptive study of breastfeeding way forward. J Hum Lact. 28(3):272-5. practices and policies in Missouri hospitals.J 4- Zakarija-Grkovic I, Šegvić O, Bozinovic T, Hum Lact. 13(2):103-7. Ćuže A, Lozancic T, Vuckovic A, Burmaz T. 15- Walsh AD, Pincombe J, Henderson A.(2011) (2012) Hospital practices and breastfeeding An examination of maternity staff attitudes rates before and after the UNICEF/WHO 20- towards implementing Baby Friendly Health hour course for maternity staff.J Hum Lact. Initiative (BFHI) accreditation in Australia. 28(3):389-99. Matern Child Health J. 15(5):597-609. 5- Abul-Fadl AM, Shawky M, El-Taweel A, 16- Haiek LN.(2012) Measuring compliance with Cadwell K, Turner-Maffei C.(2012) Evaluation the Baby-Friendly Hospital Initiative.Public of mothers' knowledge, attitudes, and practice Health Nutr. 15(5):894-905. towards the Ten steps to successful 17- Sherif H., Abul-Fadl A, Shawky M., ElTahawy breastfeeding in Egypt. Breastfeed Med. E., Elwan N. (2011) Effectiveness of a 7(3):173-8. computerized monitoring tool for the Baby 6- El-Zanaty F, Way A (2009): Feeding practices friendly Hospital Initiative in Egyptian settings. and micronutrient supplementation. In: Egypt Egyptian Journal of Breastfeeding 2: 102-114. Demographic and Health Survey 2008. 18- Tarrant M, Wu KM, Fong DY, Lee IL, Wong Ministry of Health, El-Zanaty and Associates, EM, Sham A, Lam C, Dodgson JE.(2011) International, Cairo. pp. 166–175. Impact of baby-friendly hospital practices on 7- Abul-Fadl A, Shawky M.,ElNaggar M., Elwan breastfeeding in Hong Kong.Birth. 38(3):238- N.Nowara M., Foda A., ElTaweel A., ElSherif 45. H. (2011) Assessing health staff practices that 19- DiGirolamo AM, Grummer-Strawn LM, Fein influence continuity of breastfeeding. Egyptian S.(2001) Maternity care practices: implications Journal of Breastfeeding 2: 68-78. for breastfeeding.Birth. 28(2): 94-100. 8- Shawky M., Abul-Fadl A, ElNaggar M., Elwan 20- Abrahams SW, Labbok MH.(2009) Exploring N.Nowara M., Foda A., ElTaweel A., ElSherif the impact of the Baby-Friendly Hospital H. (2011) Assessing mother friendly in Initiative on trends in exclusive maternity services in Egypt. Egyptian Journal of breastfeeding.Int Breastfeed J. 29;4:11. Breastfeeding. 2: 79-87. 21- Semenic S, Childerhose JE, Lauzière J, Groleau 9- Anwar AA., Abul-Fadl AM., Noseir M., Mahdy D. (2012) Barriers, facilitators, and MH. (2012) Promoting mother friendly recommendations related to implementing the practices as a strategy towards Baby friendly Baby-Friendly Initiative (BFI): an integrative Hosptals. Egyptian Journal of Breastfeeding 4: review.J Hum Lact. 28(3):317-34. 89-98. 22- Fletcher DM.(1997) Achieving Baby Friendly 10- Merten S, Dratva J, Ackermann-Liebrich U. through a quality management approach. Aust (2005) Do Baby-Friendly hospitals influence Coll Midwives Inc J. 10(3):21-6. breastfeeding duration on a national level? 23- Pincombe J, Baghurst P, Antoniou G, Peat B, Pediatrics.;116(5): e702-e708. Henderson A, Reddin E. (2008) Baby Friendly 11- Abolyan LV. (2006) The breastfeeding support Hospital Initiative practices and breast feeding and promotion in Baby-Friendly Maternity duration in a cohort of first-time mothers in Hospitals and Not-as-Yet Baby-Friendly Adelaide, Australia. Midwifery.24(1):55-61. Hospitals in Russia. Breastfeed Med. 1(2):71-8. 24- Perez-Escamilla R, Lutter C, Segall AM, Rivera 12- Schmied V, Gribble K, Sheehan A, Taylor C, A, Trevino-Siller S, Sanghvi T. (1995) Dykes FC. (2011) Ten steps or climbing a Exclusive breast-feeding duration is associated mountain: a study of Australian health with attitudinal, socioeconomic and biocultural professionals' perceptions of implementing the determinants in three Latin American countries. baby friendly health initiative to protect, J Nutr. 125:2972–84. promote and support breastfeeding. BMC 25- Dearden K, Altaye M, De Maza I, De Oliva M, Health Serv Res. 31;11:208. Stone-Jimenez M, Burkhalter BR, Morrow AL. 13- Owoaje ET, Oyemade A, Kolude OO.(2002) (2002) The impact of mother-to-mother support Previous BFHI training and nurses' knowledge, on optimal breast-feeding: a controlled 61
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
community intervention trial in periurban Guatemala City, Guatemala. Rev Panam Salud Publica.12:193–201.
Table 1: Comparing practices related to Step 3 by frequency distribution of mothers who received key information about breastfeeding in the perinatal period and antenatal period in two separate groups of mothers:
Information Peripartum (at During Antenatal Total arrival for delivery) visits No % No % No % (30) (30) (60) Companion at birth 0 0 7 23.35 7 16.67 Mother Friendly practices 8 26.7 28 87.3 36 60 at birth Initiation of breastfeeding 5 16.7 0 0 5 8.35 in First hour by Skin to Skin Early postpartum 11 36.7 0 0 11 18.35 practices that promote breastfeeding Hazards of formula 6 20 0 0 3 10 feeding
46.7 50 40 30 16.7 20 6 10 3 0 Early STS Late STS Prolonged STS STS by FM Figure 1: Frequency distribution of practices related to the success of Step 4 in the Baby Friendly Hospital regarding first hour skin to skin.
62
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
73.3 80 60 46.7
40 20 20
0 Early BF Initiation Early BF Initiation Late BF Initiation with STS without STS without STS
Figure 2: Frequency distribution of practices related to the success of Step 4 in the Baby Friendly Hospital regarding initiation of breastfeeding within the first hour.
100 73.3 33.3 43.3 20
0 Teach Teach Encourage Encourage mother how mother how rooming-in on demand to to express breastfeed milk Series 1 73.3 33.3 43.3 20 Figure 3: Frequency distribution of practices related to the success of Step 5, step 7 and step 8 of the Baby Friendly Hospital regarding teaching mothers breastfeeding techniques, encouraging rooming in (no early mother-infant separation) and on-demand feeding.
Supplements 66.73 80 46.7 60 30 40 13.3 20 0 Fluids Milks pacifier Feeding by spoon or cup
Figure 4: Frequency distribution of practices related to the success of Step 6 and 9 of the Baby Friendly Hospital regarding no food or drink to breastfed unless medically indicated and prohibiting pacifiers while encouraging feeding by cup or spoon.
63
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Global Practices of Expanded Updated BFHI 80 66.73 53.3 56.7 60 33.3 33.3 40 20 4.5 0
Figure 5: Frequency distribution of Mother Friendly practices (related to encouraging light food and drinks, movement, limiting cesarean sections to medical indications and using spinal anesthesia), abidance to the International code of marketing breastmilk substitutes and referring mothers to breastfeeding specialists.
23.35 25 16.7 20 10 15 6.7 10 5 0 Mother Kangaroo Expressing 6-8 Mother admission mother care times daily encouraged to feed by cup not bottle Figure 6: Percent distribution of Neonatal Intensive Care unit practices that encourage and promote breast milk feeding of neonates admitted to the unit.
64
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
التحديات التي تواجه تفعيل ممارسات المستشفيات الصديقة للطفل المحدثة في مستشفى للوالدة في اإلسكندرية -الدكتور/ أحمد فوزي* والدكتورة /هالة قدري** - األستاذ الدكتور/ صالح عبد ربه*-األستاذة الدكتورة/ عزة أبو الفضل*** * مستشفى الشاطبي الجامعي )قسم النساء والتوليد ( كلية الطب- جامعة األسكندرية ، ** المعهد العالي للصحة العامة بجامعة األسكندرية، ***رئيس جمعية أصدقاء رعاية األم والطفل ______شكر وتقدير للدعم الذي قدمه مكتب اليونيسف بالقاهرة في تنفيذ مدخالت برنامج القومي لمبادرة المستشفيات الصديقة للطفل وجهود أعضاء جمعية أصدقاء رعاية األم والطفل باألسكندرية ومديري مستشفى الشاطبي ورؤساء التمريض. ______المقدمة: مبادرة المستتتتتتتالتتتتتتتل ا ال تتتتتتتد ل طلل )BFHI( برنامج عالمي ام احد ثه مؤخرا واوستتت له ل لتتتمل الممارستتتا ال تتتد لألم واالا تتتال الج دي بوضتتتل المولود ع أل افم ور الوالدة لمدة ساع بدأ خاللها ا ائ ا بالرضاع الطب ل . الهدف: استتتاهدل الدراستتت ا م الوضتتتل الحالي لانل ل الممارستتتا المال بالخطوا الللتتتر والممارسا ال د ل طلل والل ل المدون الدول لاسو ق بدائل لبن افم. طرق البحث: ام ال ام بالا م بعد 18 شههه من اه ئ افطباء بأقستتتام افطلال والنستتتاء والاول د وادر ب الامر ض بأقستتتتتتتام نلوالدة )من نا ر إلأل ون و 2011( باستتتتتتتاخدام دورة 20 ستتتتتتتاع . وتتضههههل نلد ن هههه م ابال مل ع ن مخاارة علتتتتوائ ا من 30 من الستتتت دا الحوامل بل ادا ماابل الحمل و30 من الوالدا الالاي الرضن لوالدة طب ل ، و30 حال والدة ق ر و 30 أم من قستتتم وحدنت نلعناي المركزة لحد ثي الوالدة ل مباستتتر ن، مل إجمالي 120 أم خالل لتتتهر د سمبر من عام 2012. وقد أجر باإلسالان بافطباء الم م ن اح إلرال رئ س ال سم. النتائج : وقد أظهر الا م أن ال م الستت دا الحوامل عن الممارستتا ال تتد ل والدة الطب ل كانت أع أل )٪87.3(، في حي كان لم ام إعالم هله الستتتتتتت دا عن البدء المبكر ل رضتتتتتتتاع الطب ل من خالل الج د إلأل الج د ب نما كان الرض افمها ل بدء ي الرضتتتاع الطب ل خالل الستتتتاع افولأل عال ولكن ملظمهن بدون لا هههه لتاههههال نلد د ل د د )٪73(. وكان ادر س افمها ك ل االرضاع أ ضا مرالل )٪73.3(، ولك كان الممارسا الماب منخلض ، وتم فاههههو نلوليد م ي وق مبكر خا تتتت وتعمضهههه للا نضههههافات الستتتتوائل في )30٪( ونلح يب في )٪66.7(. والستتتتما لبعض ندوبا شههههمكات ناللباص نلاههههنامي ل اء االمها ي )33.3٪(. وبالنسب لممارسا الحضان كان ال م والج ل افم ع أل الر غ الثدى لاغل الول د من لبن افم الملا تتتر كاص تدنياً)٪16.7( ، وستتتما افم لز ارة ول دها بالحضتتتان وممارستتت رعا اه باحاضانه الج د ل ج د )في وضع نلكندم( ي ٪23.5. الخالصةةة كان الممارستتا اإلجمال منخلضتت وتشههيم للا أهم إدخال نظم ل ادر ب المستتامر وإدماج هلا البرنامج ضتتتتتتتمن مراكز الجاملا ل ادر ب المستتتتتتتامر لاطو ر المهارا المهن لألطباء وأ ضا ل امر ض لضمان اسادام مدخال البرنامج. ______
65
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Following the Steps of Men of Fortune ______On many occasions we think of business as a profit making endeavor by which we can become "rich" and make lots of "money" to get all what we need to make us "happy". But what is the definition of happiness, is it achieved by buying what you need from clothes, homes, cars or other worldly desires? What is the limit to which money can give us what we desire? And are all those "things" really what will give us the happiness we are looking for. To this end we would like to introduce genuine business men in the world of health and medicine. These men are in the business of science and make their fortune by contributing to the advancement of mankind. Their extensive riches are made at the wheels of fortune for allaying the pain and suffering of others - beyond material profit. By recognizing and acknowledging their contributions we may win the wheel of real fortune by following in their footsteps. In this issue our guest of honor to acknowledge for his contributions to NCD is Professor Edward Kaplan, currently adjunct Professor, Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis. He was the head the World Health Organization Collaborating Center for Reference and Research on Streptococci (Department of Pediatrics, University of Minnesota Medical School) for 22 years (1985-2007). His immense contribution to the literature in the scientific world for the advancement in the field of cardiology with an emphasis on rheumatic heart includes over 300 publications and over 300 abstracts. He has received countless awards from reputable scientific societies from all over the world, but in particular cardiac societies including Brazil, China, Greece, Vietnam, Australia, Philippines, India universities and societies in the United States. In Egypt, he was awarded honorary member of the Society of Cardiology and the Zahira Abdin Award from the Association of Friends of Children with Rheumatic Heart Disease in Egypt in 2008. He was visiting professor in eminent research centers in Germany and Switzerland. Professor Edward Kaplan continues to teach and contribute to the advancement of science, but mostly to his family and in particular his grandchildren. We only hope that these real men of fortune are seen as effective models for future generations who wish to make a real fortune by advancement of science for improving the health and medical care of mankind. 66
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Determinants of Vitamin D Status of Exclusively Breastfed Babies in the first six months of Life Omima M. Abdel Haie M.D., Usama A. Elfiky M.D., Anas A. Yousef M.D., Dalia E.F. Ibrahim Pediatric Department, Faculty of Medicine, Benha University Clinical Pathology Department, Faculty of Medicine, Benha University ______Abstract Background: Although exclusive breastfeeding in the first six months is ideal for babies' health, growth and development, yet there has been much controversy about the adequacy of vitamin D status in exclusively breastfed babies in the first six months of life. Aim: To assess vitamin D status in exclusively breastfed babies at 4 and 6 months in order to identify the ideal timing of vitamin D supplementation and identify the factors that predispose to vitamin D deficiency (VDD). Methodology: Thirty infants were randomly selected from a suburban clinic in Alexandria and assessed for growth (weight for age, length for age and head circumference for age) at 4 and 6 months, thorough history and clinical signs of rickets. Blood samples were drawn for study of serum levels of 25 hydroxy vitamin D (25OHVD), serum calcium (Ca), phosphorus (Ph) and alkaline phosphatase (AlkPh) twice; once at 4 and then at 6 months. Findings: Serum 25OHVD was significantly reduced (<8ng/ml) in 17 (56.7%) and 19 (63.3%) of sampled infants at 4 and 6 months respectively. Serum Ca, Ph, AlkPh were significantly lower in those with severe and marginal 25OHVD compared to the subjects with 25OHVD levels >20ng/ml, but remained within the normal cutoff levels. While growth parameters were not significantly influenced by the extent of the low 25OHVD. Lack of exposure to sunlight, maternal dietary intake, maternal supplementation during pregnancy and order in family were strongly associated with severity of vitamin DD (P<0.05). Conclusions: It is concluded that 25OHVD tends to be lower in exclusively breastfed babies who are over covered and whose mothers do take vitamin D rich food or supplements. Improving vitamin D status in exclusively breastfed babies should be attained by educating mothers to improve their dietary intake during pregnancy and lactation and encourage them to expose themselves and their babies to sunlight. Supplementing infants should be taken with caution in order to avoid the cumulative effects on the immature renal functions. ______Introduction vitamin D has different Vitamin D is an invaluable nutrient to manifestations linked to disturbed the body systems and organs. Its bone mineralization, this is action goes beyond bone homeostasis particularly important for growing to endocrine and immunological infants, where deficiency can result in actions (1). Hypovitaminosis of rickets and stunted growth (1).
67
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Exclusive breastfeeding is the exclusively breast fed infants and recommended feeding and nurturing their mothers. Also, the study aimed practice during the first six months of at identifying the risk factors life for both the mother and infant. influencing maternal vitamin D status This is so because breastmilk contains with a focus on dietary habits, all the nutrients necessary for exposure to sunlight and maternal optimum growth and development at vitamin D supplementation during this critical stage of the child‟s life pregnancy. and mother‟s need for recovery from the effects of parturition. Although Subjects and Methods vitamin D has a high bioavailability This is a cross-sectional prospective short from breastmilk, yet these babies may term follow-up study conducted for thirty be at risk of hypovitaminosis because infants from four months to six months of of the decreased exposure to sunlight, age over a 9 months period from January augmented by their poor maternally to September, 2012. acquired intakes during gestation and Selection of cases: all our cases were breastfeeding. However, there healthy normal children coming for vaccination in the medical health center of appears to be no general agreement Danna in Seyouf, in Bakous which that breast-fed infants have lower represents a suburban area in Alexandria. plasma vitamin D as compared to They were selected randomly based on a bottle fed infants and therefore may systematic method, involving selection of benefit from vitamin D every 10th case attending the medical supplementation. Conversely there is center for receiving their second dose of evidence that without the triple vaccine and polio drops at 4 supplementation, plasma 25-OH- months. After the detailed history was vitamin D (25OHVD) may often be taken from the caretaker, a blood sample low in breast fed infants (2). was drawn from the baby in the same sitting. The same mother-infant pairs were Breastfeeding, especially when then followed up at two months later (at 6 exclusive in the first critical 6 months of age) for reassessment and months, saves lives and enhances repeat blood sampling for the baby. (3) growth and development . Owing to Inclusion criteria included apparently the increasing controversy over the healthy mothers; full term baby; healthy issue of the adequacy of vitamin D infant; exclusively breastfed in the first 4 stores in these babies, particularly in months.Exclusion criteria included the later period of these six months, it history of hepatic or renal disease of the is important to understand the factors infant; history of exogenous vitamin D that may influence vitamin D status in supplementation of the infant; mothers (3) with certain infectious disease not these babies . compatible with breastfeeding or any The aim of this study is to monitor pathological disease affect vitamin D the serum level of 25OHVD, serum status; babies offered bottles and calcium, serum phosphorus and pacifiers. Ethical considerations: serum alkaline phosphatase in Consent was taken from the mothers after
68
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
they were explained the reason for with known weights. All were measured sampling. They were reassured that they and followed up by the same weight would be informed of the results and scale. The length was measured in the treated if they were found to be vitamin D supine position on a hard surface using a deficient. The logistics involved consent measuring tape to the nearest mm. The for the local health authorities of the head circumference was measured as health directorate of Alexandria Ministry occipitofrontal diameter of the baby‟s of Health. bare head using a measuring tape to the Data Collected: nutritional history of nearest mm. Signs of rickets were the mother during pregnancy and determined clinically by wide anterior lactation, types and dietary intake, intake fontanelle, craniotabes, rachitic rosaries of vitamin supplements or other and broad epiphysis. medication that may interfere with Laboratory studies: A blood sample vitamin D. Developmental history (5ml) was drawn by a laboratory including emerging behavioral gross and technician at the medical center under fine motor skills, social and aseptic conditions at 4 and at 6 months of sensorineural development for hearing, age. It was collected in vials with EDTA vision and speech. Living habits and transported in an ice box to the including indoors or out door habits, central laboratories of the Ministry of clothing and wrapping of the infant and health in Alexandria. Measurement the mother, extent of sun exposure including serum 25-OHVD level by radio time and duration of exposure of both immunoassay (RIA), serum calcium, mother and baby. A history of phosphorus and alkaline phosphatase hospitalization or admission of the baby levels by colorimetric methods. to the neonatal intensive care unit was Principle of the test: This 25-OHVD recorded, with details about reason and enzyme linked immunosorbent assay duration or stay. A detailed feeding applies a technique called a quantitative history included feeding patterns from sandwich immunoassay. The microtiter birth, introduction of supplements, infant plate provided in this kit has been pre- milk formula, foods or bottles or pacifiers coated with a monoclonal antibody at any time during the first months of life. specific for 25-OHVD. Standards or Frequency of feeding, night feeds, any samples are then added to the microtiter problems arising during feeding, and plate wells and 25-OHVD if present, will adequacy of the breastfeeding positioning bind to the antibody pre-coated wells. In and attachment. A thorough examination order to quantitatively determine the was done to exclude major congenital amount of 25-OHVD present in the anomalies. Examination of chest and sample, a standardized preparation of heart and abdomen was performed to horseradish peroxidase (HRP)-conjugated exclude any organomegaly or chronic polyclonal antibody, specific for 25- disease. OHVD are added to each well to Anthropometric measures: The weight “sandwich” the 25-OHVD immobilized was assessed using a standard weight on the plate. The microtiter plate scale in the medical centers. The baby undergoes incubation, and then the wells was measured with light clothes and are thoroughly washed to remove all weight to the nearest gram after adjusting unbound components. Next, A and B for extra clothes after standardization substrate solution is added to each well.
69
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
The enzyme (HRP) and substrate are to 5 with the mean of 2.21±2.09. Previous allowed to react over a short incubation abortion was found in 4 (13.33%). period. Only those wells that contain 25- Exposure to sun was reported in 17 OHVD and enzyme-conjugated antibody (56.67%). Women who were completely will exhibit a change in colour. The covered in clothing included 7 (23.33%), enzyme-substrate reaction is terminated while those freely clothed were 23 by the addition of a sulphuric acid (76.67%). Most of the studied women 19 solution and the colour change is (63.33%) had taken vitamin D during measured spectrophotometrically at a pregnancy. wavelength of 450 nm. Interpretation of Severe vitamin D deficiency (<8 ng/ml) results: the normal range of 25-OHVD was detected in 17 cases at 4 months and ranges from 30-125 nmol /l (1 ng/ml = 19 cases at 6 months. Marginal vitamin D 2.5 nmol/l, 1 nmol/l = 0.4 ng/ml) deficiency (8-<20 ng/ml) was detected in whereby serious deficiency is <12ng/ml, 6 cases at 4 months and 5 cases at 6 insufficiency (moderately deficient) 12- months. Normal vitamin D levels (>20 30ng/ml, sufficiency (adequate supply) ng/ml) were detected in 7 cases at 4 >30ng/ml(4). months and 6 cases at 6 months Statistical analysis: Statistical analysis At 4 months: severe vitamin D deficiency was done using the SPSS software was detected in 9 (50.0%) and 8 (66.7%), package version 17.0 Statistical analyses while marginal vitamin D level was was done to obtain the mean, the standard detected in 4 (22.2%) and 2(11.1%) and deviation; the standard error of each normal levels of vitamin D in 5 (27.8%) mean and for comparison between the and 2 (11.1%) in males and females different groups involved in this study respectively. The Chi-square (X2) was used for At 6 months: severe vitamin D deficiency comparison between distribution of was detected in 10 (55.6%) and 9 patients according to different items of (75.0%), while marginal vitamin D level study. ONE WAY test was used for in 3(16.7%) and 2(11.1%) and normal comparison between independent levels of vitamin D in 5(27.8%) and samples. One Way Analysis of Variance 1(5.6%) in males and females (ANOVA) was performed for comparison respectively as shown in figure (1). There between more than two samples using the was no statistically significant variance ratio “F”. The probability "p" relationship between gender and infant value was obtained from special table for vitamin D status (P<0.05). probability (p) value, according to the Order of child in the family: at 4 months, degree of freedom with a cut off of severe vitamin D deficiency status was P<0.05. found in 4 (44.4%), 5(62.5%), 5 (62.5%) and 3 (60.0%), marginal vitamin D level Results was found in 0(0.0%), 2(25.0%), 2 (25.0%) and 2 (40.0%), normal level of The characteristic ethnographic features vitamin D was found in 5 (55.6%), 1 of mothers showed that 9 (30.0%) of (12.5%), 1 (12.5%) and 0 (0.0%) at 1st, mothers were less than 25 years, 11 2nd, 3rd and 4th or more, there were no (36.67%) were between 25-35 years and statistical significant differences. At 6 10 (33.33%) were more than 35 years old. months, severe vitamin D deficiency Gravidity ranged between 1-5 with the status was found in 4(44.4%), 4 (50.0%), mean of 2.35±2.44. Parity ranged from 1 70
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
6 (75.0%) and 5 (100.0%), marginal Biochemical markers related to vitamin D vitamin D level was found in 0 (0.0%), deficiency: At 4 months, the mean of 3(37.5%), 2(25.0%) and 0 (0.0%), normal Calcium (Ca) levels was 8.981.6, level of vitamin D was found in 5 8.651.52, 10.980.9 for severe, (55.6%), 1 (12.5%), 0 (0.0%) and 0 marginal and normal vitamin D status (0.0%) at 1st, 2nd, 3rd and 4th or more. respectively, there were statistical Hence most of the severe vitamin D significant differences. At 6 months, the deficient states were found among infants mean of Ca level was 7.981.8, of the 4th order or more, this was 8.981.61and 11.91.3 for severe, statistically significant at P<0.05. marginal and normal vitamin D status Exposure to sunlight: at 4 months: severe respectively. There were statistically vitamin D deficiency was found in 3 significant differences between Ca levels (25.0%) and 14 (77.8%), marginal of the infants at 4 and 6 months (P<0.05) vitamin D level was found in 3(25.0%) (Table 3). and 3 (16.7%), while normal vitamin D At 4 months, the mean of Phosphate (Ph) level was found in 6 (50.0%) and 1 levels was 3.1±0.66, 4.1±1.9 and 4.5±1.9 (5.6%) for exposed and not exposed for severe, marginal and normal vitamin groups respectively .At 6 months severe D status respectively; there were no vitamin D deficiency was found in 4 statistical significant differences. At 6 (33.3%) and 15 (83.3%), marginal months, the mean of Ph levels were vitamin D level was found in 3(25.0%) 3.1±1.33, 4.2±1.9 and 4.7±1.8 for severe, and 2 (11.1%), while normal vitamin D marginal and normal vitamin D status level was found in 5 (41.7%) and 1 respectively. There were no statistical (5.6%) for exposed and not exposed significant differences between the groups respectively. Normal Vitamin D infants at 4 and 6 months regarding status was found in exposed higher than Phosphate levels (P<0.05) (Table 3). not exposed. There were statistically At 4 months, the mean of alkaline significant differences between vitamin D phosphatase level was 1189±88.01, status of the infants at 4 and 6 months 10.62.85±109.84 and 983.14±120.26, for regarding sun exposure (P<0.05) (Figure severe, marginal and normal vitamin D 1). status respectively, there were statistical Maternal dietary intake of diets rich in significant differences. At 6 months, the vitamin D, and supplementation during mean of alkaline phosphatase level was pregnancy: There was a statistically 1263.79±108.85, 1132.05±101.40 and significant difference between vitamin D 976.882±74.889 for severe, marginal and status of infants at 4 and 6 months in normal vitamin D status respectively as relation to maternal dietary intake versus shown in table (3). There were statistical supplementation as shown in figures 2 significant differences between the and 3 respectively. infants at 4 and 6 months regarding Growth parameters: There were no alkaline phosphatase level (P<0.05) significant clinical differences between (Table 3). infants at 4 and 6 months in relation to Discussion severity of VDD and anthropometric measures of weight for age, length for Hypovitaminosis D occurs because age and head circumference for age sun exposure is extremely limited for P>0.05 (Table 2). both mothers and infants and dietary
71
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
supplementation at the current optimal vitamin D status during the adequate intake (AI) of 400 IU/d is first 5 months of life, as evidenced by inconsequential. Vitamin D levels low serum 25-OH D concentrations also vary according to race and (9). degree of pigmentation, season, and Several factors affect vitamin D status latitude (5). of exclusively breast-fed infants and Vitamin D supplementation of breast- these include sex , birth order , sun fed infants remains a matter of exposure , skin color and ethnicity(4). controversy all over the world. It has In this study there were no significant been reported that, unsupplemented differences between boys and girls in human milk fed infants showed no our study. However, a study in evidence of vitamin D deficiency Egyptian settings showed that boys during the first 6 months of life(6,7).. were more sensitive to any significant Other workers (3) suggested that, fetal lack or reduction of vitamin D than stores of vitamin D may be rapidly girls. The workers attributed this to depleted and that breast milk may be cultural factors since such mothers inadequate as the only source of may tend to be overprotective of male vitamin D even for breast fed infants offspring, keeping them indoors and of vitamin D supplemented mothers. heavily wrapping them in clothes to In this current study over one half of avoid the "evil eye" (10). the cohort infants at 4 months and As regards to order in family, we two thirds at six months who were found that the fourth order or more exclusively breastfed had severe were worst off. Such findings agree vitamin D deficiency. This high with the previous study workers who prevalence agrees with the findings reported that vitamin D status reported by other workers (8) who appeared to worsen by the increasing studied 90 unsupplemented healthy order of birth. This was probably term breast-feeding Arab/south Asian related to the short intervals in- infants and their mothers. The infants between child births and inadequate were studied between ages 4 to 16 dietary supplementation leading to weeks (median 6 weeks).The mean depletion of the maternal stores (10). serum 25-OH-D concentrations was In this study findings indicated that 4.6 ng/ml which indicate that 82% of exposure to sunlight played a the infants had hypovitaminosis D. significant role in determining the A study for Korean infants, showed risk to develop vitamin D deficiency. “suboptimal” stores of vitamin D at One of the main sources of vitamin D birth as evidenced by extremely low in exclusively breast-fed infants is the cord levels of serum 25-OH vitamin endogenous synthesis from the skin D. They suggested that the low 7-dehydrocholesterol by the action of prenatal stores, combined with the ultraviolet B radiation . The estimate infants‟ low intakes of vitamin D of ultraviolet score needed to from breast milk, are not adequate for maintain a serum 25-OHD of 11ng/ml
72
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
is a minimum of 24 minutes over the mild vitamin D deficiency may have day with only the face uncovered only modest decrease in serum (11,12,13). calcium , phosphate or both (20). Although in our study, we did not The vitamin D status correlates notice any effect of darker skin being closely with the rate of growth. a risk to VDD, probably due to small Individuals with VDD often have number of dark skinned subjects in slower rates of growth. The our sample. However, many other characteristics of growth in breastfed workers have shown the relationship have been shown to be very rapid in between dark skin and VDD as the first three months of life, melanin in the skin has an inverse thereafter it slows at 4 to 6 months correlation with vitamin D synthesis (21). This physiological slowing allows (14,15,16). for important transitional adaptation Our study showed a significant effect processes in the tissues and organs to as regards maternal dietary intake and take place. Hence the decrease in maternal vitamin D supplementation vitamin D levels in this period may during pregnancy. Other workers have reflect a physiological adaptation to shown that a daily postpartum the growth patterns of breastfed maternal supplementation with 2000 babies. Moreover it could be argued IU of vitamin D but not with 1000 IU that the cutoffs of vitamin D in these was similar to the infants who infants may need to be lower than that received daily 400 IU of vitamin D of adults simply because of the (17). Available evidence indicates that increased sensitivity of the immature if the vitamin D status of the lactating tissues and organs and the high rate of mother is adequate, her nursing infant growth and risk of hypercalcemia will maintain a “minimally normal” when high doses are given to babies nutritional vitamin D status (18). very early in life (22, 23). Maternal Maternal vitamin D supplementation supplementation is safer and can in pregnancy is another important achieve the same levels in babies who factor which plays a role in infant are supplemented but without any vitamin D status especially through side effects (24, 25). early neonatal life through In conclusion Breastmilk provides transplacental passage (19). Although adequate nutrients when we found no clinical evidence of breastfeeding practices are rickets, yet biochemical findings of appropriate. Improving breastfeeding calcium and alkaline phsophatase practices of exclusively breastfed paralleled the low vitamin D. The babies can optimize nutrient intake clinical presentation of vitamin D from mother's milk. Breast milk deficiency may be subtle. Patients especially hind milk is rich in vitamin with severe vitamin D deficiency may D and every attempt should be made present with symptoms and signs of to assist and guide mothers to hypocalcemia, whereas patients with optimize her breastfeeding practices.
73
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
However babies who are living in for vitamin D supplementation. AMB cultures that deprive them of sunlight News Views Newsl. 7:1-5. by over-clothing, poor housing 7- Glerup H, Mikkelsen K, Poulsen L, et al. (2000) Commonly recommended conditions or whose mothers are daily intake of vitamin D is not themselves deprived of adequate sufficient if sunlight exposure is limited exposure to sunlight may be at risk of . J Intern Med. 247:260. VDD. Although supplementation may 8- Dawodu A, Agarwal M, et al. (2003) be required in such babies it would be Hypovitaminosis D and vitamin D in more advisable to encourage these exclusively breast-feeding deficiency infants and their mothers in summer: a mothers and their babies to increase justification for vitamin D their exposure to sunlight, particularly supplementation of breast-feeding in the early morning (ultraviolet rays). infants. J pediatr. 142: 169-73. Maternal dietary supplementation 9- Park M, Namgung R, Hikim DUK, et al. rather than supplementation of infants (1998) Bone mineral content is not is safer and is recommended under all reduced despite low vitamin D status in situations. breast milk–fed infants versus cow milk based formula – fed infants . J Pediatr. References 132: 641 – 5. 1- Holick MF. (2004) Vitamin D: 10- EL-Mougi M, EL-Malki F, EL-Akkad importance in the prevention of cancers, N, et al. (1990) Epidemiological study type 1 diabetes, heart disease, and of vitamin D deficiency rickets among osteoporosis. Am J Clin Nutr. 79: 362- infants and children. The New Egyptian 71. Journal of Medicine. 4: 1-3 2- Dror DK, Allen LH .(2010) Vitamin D 11- Haddad JG, Matsuoka LY, Hollis BW, inadequacy in pregnancy: biology et al. (1993) Human plasma transport of outcomes, and interventions. Nutr Rev. vitamin D after its endogenous 68(8):465–477. synthesis. J Clin Invest. 91(6):2552- 3- Lauer JA, Betran AP, Barros AJ, de 2555. Onis M. (2006) Deaths and years of life 12- Gartner LM, Greer FR. (2003) lost due to suboptimal breast feeding Prevention of rickets and vitamin D among children in the developing deficiency: New guidelines for vitamin world: a global ecological risk D intake. American Academy of assessment. Public Health Nutr. 9: 673- Pediatrics. 111: 908-10. 85. 13- Dawodu A, Dawson KP, Amirlak I, et 4- Holick MF. (1990) The use and al. (2001) Diet, clothing, sunshine interpretation of assays for vitamin D exposure and micronutrient status of and its metabolites. J Nutr. 120 Suppl Arab infants and young children . Ann 11: 1464 – 9 . Trop paediatr. 21: 39-44. 5- Scanlon KS, Cogswell ME, et al. (2002) 14- Kreiter SR , Schwartz RP , Kirkman HN Hypovitaminosis D prevalence and , et al. (2000) Nutritional rickets in determinants among African American African American breastfed infants. J and white women of reproductive age: pediatr. 137. 153 – 157. Third National Health and Nutrition 15- Nicholas S, Melanie K. (2004) Vitamin D deficiency in children. In: Timothy J. Examination Survey: 1988–1994. Amer st J Clin Nutr. 76:187–192. D. Recent advances in Pediatrics. 21 6- Kreiter S. (2001) The reemergence of ed. London: Royal Society of Medicine vitamin D deficiency rickets: the need press ltd. 85 – 100. 74
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
16- Barger-Lux MJ, Heaney RP (2002) breastfed infant.Pediatr Clin North Am. Effects of above average summer sun 48(1):87-104. exposure on serum 25-OHD and 22- Gallo S, Comeau K, Vanstone C, calcium absorption. J Clin Endorinol Agellon S, Sharma A, Jones G, et al. Metabol. 87: 4952 – 6. (2013) Effect of different dosages of 17- Hollis BW and Wagner CL. (2004) oral vitamin D supplementation on Assessment of dietary vitamin D vitamin D status in healthy, breastfed requirements during pregnancy and infants: a randomized trial.JAMA. 1; lactation. Am J Clin Nutr. 79 (5):717- 309(17):1785-92. 726. 23- Abrams SA. (2013) Targeting dietary 18- Cancela L, LeBoulch N, Miravet L. vitamin D intakes and plasma 25- (1986) Relationship between the Hydroxyvitamin D in healthy infants. vitamin D content of maternal milk and JAMA. 309(17):1830-1831. the vitamin D status of nursing women 24- Wagner CL, Hulsey TC, Fanning D, and breastfed infants. J Ebeling M, Hollis BW. (2006) High- Endocrinol.110:43–50. dose vitamin D3 supplementation in a 19- Taylor SN, Wagner CL, Hollis cohort of breastfeeding mothers and BW.(2006) Maternal or neonatal their infants: a 6-month follow-up pilot vitamin D supplementation during study.Breastfeed Med. 1(2):59-70. lactation: What is the better option? 25- Cranney A, Horsley T, O'Donnell S, Annu Rev Nutr. Epub 2006 Jun 28. Weiler H, Puil L, Ooi D, et al. 20- Gloth FM, Tobin JD. (1995) Vitamin D (2007).Effectiveness and safety of deficiency in older people. J Am Geriatr vitamin D in relation to bone Soc. 43:822. health.Evid Rep Technol Assess (Full 21- Dewey KG. (2001) Nutrition, growth, Rep). 158:1-235. and complementary feeding of the
Table (1): Vitamin D status of infants at 4 months and 6 months
Age group X2 Vitamin D status 4 months 6 months P No. % No. % Severe vit. D. deficiency (25 OH vit. D <8 ng/ml) 17 56.7 19 63.3 0.279 Marginal vit. D. level (25 OH vit. D 8 to <20 ng/ml) 6 20.0 5 16.7 0.870 Normal vit. D. level (25 OH vit. D 20 to 60 ng/ml) 7 23.3 6 20.0 2: Chi square test *: Statistically significant at p ≤ 0.05
75
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
100 Exposed Not exposed 90
80
70
60
Percentage 50
40
30
20
10
0 Severe Marginal Normal Severe Marginal Normal
4 months 6 months Figure (1): Vitamin D status of infants at 4 and 6 months in relation to sun exposure *: Statistically significant at p ≤ 0.05
90 Poor vit.D supply Rich vit.D supply 80
70
60
50 Percentage 40
30
20
10
0 Severe Marginal Normal Severe Marginal Normal
4 months 6 months
Figure (2): Vitamin D status of infants at 4 and 6 months in relation to maternal dietary habits.
76
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
100 Yes No 90
80
70
60
Percentage 50
40
30
20
10
0 Severe Marginal Normal Severe Marginal Normal
4 months 6 months
Figure (3): Vitamin D status of infants at 4 and 6 months in relation to maternal vitamin D supplementation during pregnancy. Table (2): Vitamin D status of infants at 4 and 6 months in relation to anthropometric measurements.
4 months 6 months
Severe Marginal Normal Severe Marginal Normal Wt Mean ± SD 5.24±1.4 5.8±1.1 6.5±1.0 6.98±1.5 7.14±1.3 8.03±1.6 F 2.503 1.138 P 0.101 0.335 Length Mean ± SD 56.6±7.1 59.6±6.8 58.3±7.2 59.3±5.65 65.3±6.2 64.9±6.9 F 0.445 3.259 P 0.646 0.054 Head
Circumference Mean ± SD 39.6±5.0 40.1±4.2 40.5±3.2 39.8±5.33 40.6±3.98 40.7±2.3 F 0.105 0.113 P 0.900 0.894 Fp: p value for F test (ANOVA)
77
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Table (3) Vitamin D status of infants at 4 and 6 months in relation to serum calcium, phosphorus and alkaline phosphatase level 4 months 6 months
Severe Marginal Normal Severe Marginal Normal Ca level Mean ± SD 8.98±1.6 8.65±1.52 10.98±0.9 7.98±1.8 8.98±1.61 11.9±1.3 F 5.609* 12.266* P 0.009 <0.001 Ph. level Mean ± SD 3.1±0.66 4.1±1.9 4.5 ± 1.9 3.1±1.33 4.2±1.9 4.7±1.8 F 3.297 2.984 P 0.052 0.067 Alkaline phosphat ase
Mean ± 1189.83±88. 1062.85±109 983.14±120 1263.79±108 1132.05±101 976.882±74. SD 01 .84 .26 .85 .40 889
8.528* 27.252*
P 0.001 <0.001 Fp: p value for F test (ANOVA) *: Statistically significant at p ≤ 0.05
78
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
العوامةةل التةةى تةةرثر علةةى مسةةتوم فٌتةةامٌن "د" فةةً الرضةةع الةةنٌن ٌمارسةةون الرضاعة الطبٌعٌة المطلقة خالل ال6 شهور األولى من العمر اىذمح٘سة / أٍَٞة عثذ اىسٜ* ، األسحبر اىذمح٘س /أسبٍة اىفقٜ *األسحبر اىذمح٘س/ أّس ٝ٘سف **، اىذمح٘سة/ داىٞب ئبشإٌٞ^ *قسٌ غب األغفبه ميٞة اىطب بْٖب- خبٍعة بْٖب - ** قسٌ اىنَٞٞبء اىثبث٘ى٘خٞة ميٞة غب – خبٍعة بْٖب ،^ ٗصاسة اىصسة ______اىخيفٞرة: عٍدٝ زٌددشغُ ِدٓ أْ زٌشظدسعع زٌطط١ة١ددع زٌخسٌصدع فددٟ زألشدٙش زٌغدؽع زألٌٚددٝ ِفس١ٌدع ٌّٕددٛ زألغفددسي ؼةض٠ددض صددىٙؽُ جي أْ ٕ٘ددسن زٌىف١ددش ِددٓ زٌمددذي وددٛي ِددذٜ وفس٠ددع فؽ١ددس١ِٓ )د( فددٟ وسٌددع زألغفسي زٌشظع سظسعع غط١ة١ع خسٌصع فٟ زألشٙش زٌغؽع زألٌٝٚ ِٓ زٌى١سظ. اىٖذف: ؼم١١ُ وسٌع فؽ١س١ِٓ "د" فٟ زألغفسي زٌشظع سظسعع غط١ة١ع خسٌصع فٚ 5 ٟ 8 أشٙش ِدٓ ألددً ؼىذ٠ددذ ٛؼل١ددػ ِفددسٌٟ ِددٓ ِىّددالغ فؽ١ددس١ِٓ "د" ٚزؽٌةددشف عٍددٝ زٌةٛزِددً زؽٌدد١ٙؼ ٟددد ٌددٕم فؽ١س١ِٓ "د". اىْحرربئح: وددسْ ٕ٘ددسن جٔخفددسض ضكددىً ٍِىددٛو فددٟ ٔغددطع فؽ١ددس١ِٓ "د" فددٟ زٌددذَ فددٟ )..٪08( ٚ)83.3٪( ِٓ زألغفسي زٌشظع فٟ عٕذ ٚ 5 8 أشٙش ِٓ زٌةّش عٍٝ زٛؽٌزؼٚ .ٌٟطع رٌه جٔخفدسض ِٛزودددص فدددٟ ٔغدددطع زٌىسٌغدددٛ١َ، زٌفغدددفسغ ٚجٔدددض٠ُ زٌفٛعدددفس١ؼض زٌمٍدددٞٛ ضكدددىً ٍِىدددٛو فدددٟ ٘دددزٖ زٌّمّٛعددسغ ٌٚىددُٕٙ وٍددٛز ظددّٓ زٌّغدد٠ٛؽسغ زٌفغددٌٛٛ١ل١ع زٌّمطٌٛددع ضددذْٚ وٙددٛس أ٠ددع أعددشزض عددش٠ش٠ع ٌٍدد١ٓ زٌةاددسَ. ٚزسؼططددػ زؽٌٕددسذك ضّىددذدزغ ِفددً عددذَ زؽٌةددشض ألشددةع زٌكددّظ ٚزؽٌغط١ددع زٌضزذذظ ٌٍطفً ٚ عذَ ؼٕسٚي زألَ ٌٍّىّالغ زٌغززذ١ع خدالي فؽدشظ زٌىّدً ٚزٌشظدسعع زٌغ١ٕدع ضفؽ١دس١ِٓ "د" ٚعذد ِشزغ زٌىًّ ٚزٌٛيدظ ٚزٌّطسعذظ ض١ٓ فؽشزغ زٌىًّ. زالسحْحبخبت: ٠ٚغؽٕؽك ِٓ رٌه أْ ٔغطع فؽ١س١ِٓ "د" ١ّ٠ً جٌٝ أْ ٠ىْٛ ألً فدٟ زألغفدسي زٌشظدع سظسعع غط١ة١ع خسٌصع زٌز٠ٓ ي ؽ٠ةشظْٛ ألشةع زٌكّظ ٚلٍع ؼٕسٚي زألِٙسغ ٌٍّىّالغ زٌغززذ١ع زٌغ١ٕددع ضفؽ١ددس١ِٓ "د"، ٌٚددزٌه ؽ٠ىمددك ؼىغدد١ٓ زٌٛظددع فؽ١ددس١ِٓ "د" فددٟ زٌشظددع ضؽىف١دد زٛؽٌع١ددع زٌغززذ١ددع أـٕددسء زٌىّددً ٚزٌشظددسعع ؼٚكددم١ةُٙ عٍددٝ زؽٌةددشض ألشددةع زٌكددّظ. ٚي ٠ٕصدده ضحدخددسي فؽ١س١ِٕسغ جظسف١ع ٌألغفسي ٌىّس٠ع أٔغدمٙؽُ ِدٓ ؼدأـ١ش ؼدشزوُ ؼٍده زٌةمدسل١ش فدٟ لغدٚ ُّٙ زٌّعدسس زؽٌّصٍع ضزٌه. ______
79
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Nutritional status and Co-morbidities Influence Evolving Disease Pattern of Rheumatic Heart in Egypt Azza MAM Abul-Fadl, MD.* Alaa Ghamrawy MSc.**, Hesham Sherif MSc** *Pediatric Department, Benha Faculty of Medicine, Benha University, **Ministry of Health in Egypt (This paper is a subset analysis of the some of the Egypt data of the REMEDY project, Cape Town University, South Africa) ______Abstract Introduction: Over the past decades the pattern of rheumatic heart disease (RHD) has changed. The underlying causes are poorly understood. The extent to which other endemic diseases as Bilharziasis, hepatitis B and C (HBV, HCV), hypertension and obesity influence the pattern of RHD is controversial. Aim: To assess the prevalence of concomitant comorbidities in patients with RHD and their effect on the disease pattern. Methodology: Patients were recruited from the Rheumatic heart center of Mahalla in Gharbia governorate that were enrolled in the multicenter REMEDY study conducted in collaboration with Cape Town University in South Africa. Forty patients from the registry had being confirmed by echocardiography studies and followed up for one year. They were further investigated for HCV antibodies and HBsAg status routine tests for Bilharziasis, body mass index (BMI) and blood pressure (BP) measurements. Findings: Ages ranged from 5.5 to 23 years. Female to male ratio was 3:2. The majority of cases were mitral regurgitation in 72.5% followed by combined MR and aortic regurgitation in 12.5%. Serological tests were positive for HCV in 45%, 22.5% for HBV and Bilharziasis in 30% with females affected twice as common as males. Comorbidity with more than one disease was more common in females and was associated with multiple valve disease. BMI ranged from 24 to 42 and was more common in females and was associated with multiple valve disease with high BP detected in 2 females with obesity. Conclusions: Comorbidity with multiple diseases is an emerging finding among RHD patients living in endemic areas and affects the disease pattern especially among females with concomitant poorer prognosis. There is a shift in the paradigm of disease relationship to the malnutrition from underweight to overweight and obesity. There is a need for preventive programs to address non-communicable diseases in an integrated and comprehensive approach by screening for early detection and treatment of concomitant diseases and malnutrition states. Introduction poor and developing countries. The burden of rheumatic fever (RF) Rheumatic heart disease (RHD) and rheumatic heart disease (RHD) remains a major public health continues to be a major contributor to problem in developing countries. morbidity and premature death in Whereas Africa has 10% of the
80
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
world's population, as many as half of overnutrition, particularly the latter, the 2.4 million children affected by are emerging as significant RHD globally live on the continent. morbidities in developing countries RHD accounts for a major proportion caused by the sedentary life and poor of all cardiovascular disease in eating habits. Studies of prevalence of children and young adults in African such disorders among RHD patients countries (1,2). While acute rheumatic have been minimal and controversial fever is on the decline even in the and has ranged from reports of low developing world, there are still a prevalence of HBV and HCV in large number of chronic rheumatic rheumatic patients (6) to some heart disease cases, often complicated exposure in other studies(7). by chronic congestive heart failure The purpose of this study is to and recurrent thrombo-embolic examine the prevalence and phenomena, both posing greater determinants of co-morbidities in challenges for management (3,4). patients who are already suffering Subclinical carditis occurs only in the from rheumatic heart disease. first-episode patients, which requires Methodology early detection by echocardiography. This is a cross sectional follow-up cohort Most deaths occur in recurrent RF study of 40 patients attending the group hence secondary prophylaxis Rheumatic heart center in Mahalla, and management of sore throat need Gharabia governorate in Egypt. The re-emphasis(5). Valvular involvement patients were selected from the cases in patients with RHD is the major recruited from the REMEDY of Cape Town University in South Africa from the cause for their disability mainly the period from 2010 to 2012. In addition the mitral valve, followed by the aortic study was a part of the University of valve. In the absence of secondary Benha thesis for PHD degree in pediatrics prophylaxis recurrent episodes of RF in collaboration with the Ministry of can lead to RHD with considerable Health after obtaining official approvals disability and mortality in children. from the University board of directors and The role of comorbidties in the Ministerial officials centrally and from progression of the disease and its the governorate. complications has not been A detailed format of questionnaire were intensively studied. In Egypt there is a taken for the patients in which the Egyptian collaborators added an high prevalence of hepatitis C and additional set of data with regards status hepatitis B despite the inclusion of of patients with regards positivity to hepatitis B (HBV) vaccination within serological testing to hepatitis C by the national program of polymerase chain reaction (PCR) testing immunization. and hepatitis B surface antigen using Schistosomiasis remains a problem ELISA tests. In addition testing for among the rural communities in Schistosomiasis was done for all patients Egypt. Moreover nutritional by routine urine and stool analysis. problems; whether under or Detailed echocardiography examination was conducted for all patients to assess 81
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
valvular affection, cardiac chamber size Gender distribution showed that 9 females and function in addition to pulsed wave (69.2%) were positive for HBV compared and continuous wave (PW and CW) and to only 4 males (30.7%), similarly for colour Doppler to assess valvular lesions HCV affection in females was double that (regurgitation and stenosis). of males (12 or 66.7% versus 6 or 33.3% respectively. Bilharziasis or Data was compiled and presented in Schistosomiasis was 3 times more frequency distribution tables. Statistical common among females than males (9 or analysis was done using chi-square and 75% versus 3 or 25% respectively). cut offs of P<0.05 for statistical Co-morbidity with more than one significance. endemic disease was seen in 4 females Findings versus 2 males for HBV and HCV, and 4 females versus one male for HCV with The cases were analyzed by frequency Bilharziasis and finally one female with distribution for descriptive purposes. The HBV and Bilharziasis and one male with findings are presented in figures 1 to 8. HBV, HCV and Bilharziasis. Valvular lesions: The 40 cases were Nutritional status and hypertensive subsets of the REMEDY study, in which disease: Nine cases had a diastolic cases had undergone previous pressure of over 90mmHg (22.5%), and 8 echocardiography studies to confirm the cases had a diastolic pressure of over valvular lesions present. Mitral 140mmHg of who two were females. regurgitation (MR) whether isolated or in High Body mass index (BMI) ranging combination with another lesion was from 24 to 42 was present in 14 cases present in 39 cases only one patient had comprising 11 females and 3 males an isolated mitral stenosis (MS). increasing with age. Two cases had combined MR and MS. Co morbidity and valvular disease Nine cases had combined lesion of MR pattern: Two female patients who had with aortic regurgitation (AR). One case right sided valve affection TR or PR were had MR with tricuspid regurgitation (TR) HCV positive. While 4 out of the 5 and another had MR, AR with pulmonary females, who had combined MR and AR, regurgitation (PR). Nine females had were positive for Schistosomiasis (one combined or multiple lesions compared to also positive for HCV). In males only 4 males who showed multiple valve combined lesions of MR and AR were not lesions. associated with evident comorbidity. Six Sex distribution and age range: The females who had either combined left male to female ratio was 2:3 with 16 sided or right sided valvular lesions, had males and 24 females. Only one case was high BMI over 25 and high systolic and below 6 years of age (5.5 years), 8 cases diastolic blood pressures. Figure 1 shows (20%) were 6-11 years of age, 25 cases the distribution the cases according to (62.5%) were 11-18 years of age and 6 their valvular affection. (15%) were 18-23 years of age. Comorbidity: Distribution of RHD by Discussion comorbidity showed that 18 cases (45%) A significant portion of our cases were positive for HCV, 9 cases (22.5%) were females 3:2. Our cohort were positive for HBV and 12 cases presented with mitral regurgitation (30%) were positive for Schistosomiasis. (MR) (72.5%) and with both MR and 82
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
AR in 18%. Isolated MS was rare morbidity among females. One half of (2.5%). One case had both MR and our patients suffered more than one TR and another had MR with PR, comorbidity and of these one half had both were HCV positive. This is in more than one comorbidity from agreement with a study in Nigeria that endemic diseases as schistosoma, showed that females were commonly HBV or HBC with a male to female more affected than males with a ratio ratio ranging from 1:2 to 1:3 for of 1:1.7) and their ages ranged from 5 single or multiple comorbidities to 60 (mean 24.02 +/- 12.75) years. respectively. Only one study was Mitral regurgitation was the reported to screen RHD among other commonest echocardiography groups for HBV and HCV positivity. diagnosis in over one half and mixed They reported no increased mitral with aortic in one third. prevalence (6). This is contradictory to Complications of RHD were common our finding and may be explained by and included secondary pulmonary regional differences in endemicity and hypertension in two thirds, valvular difference in timing of the study with cardiomyopathy and functional the increased prevalence of tricuspid regurgitation in one third (8). malnutrition owing to the multiple Another study in Nepal(9) reported that exposures to the epdemics of avian female patients were significantly virus and other viruses attacking older as compared to male patients at poultry and cattle and depriving the time of presentation and more growing children of an important commonly presented with mitral source of protein in their diet. stenosis as compared to male patients In Egypt seroprevalence for hepatitis with a peak between the age of 30 and infection were 19.6% for HBV, 24% 49 years. Conversely, aortic to 10.3% for HCV, and 5% both HBV regurgitation was more common in and HCV. The prevalence of HBV men as compared to women. and HCV markers generally increased Involvement of both the mitral and the with age. Some workers found no aortic valve was observed in 49.8% of association with either sex, S. the patients and was more common in mansoni infection, or schistosomal men as compared to women(9). A periportal fibrosis. HBV seropositivity study in Bangladesh showed that was not associated with increased risk males predominated over females in of HCV seropositivity. Anti-HCV MS (male/female = 1.2/1) and the seropositivity was significantly incidence of pulmonary hypertension associated with previous parenteral in MS was higher in Bangladesh (10). treatment for schistosomiasis and Such findings of female history of previous surgery. Other preponderance of RHD are in workers reported a decrease in coherence to our findings. prevalence with improved In addition the current study shows a socioeconomic status(14). Risk factors higher tendency to exposure to co- associated with the high prevalence of
83
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
HCV include age, risk factors workers have studied prevalence in included age; male gender; blood Alexandria and showed evidence of transfusion; invasive medical multiple infections between hepatitis procedure (surgery, catheterization, and schistosoma with double in 66% endoscopy, and/or dialysis), injections (anti-HCV and anti-SEA), triple in from "informal" health care provider 33% (anti-HCV HBsAg and anti- and cesarean section or abortion. SEA). The presence of anti-HCV was Exposures not significantly related to independently associated with anti-HCV positivity in adults previous parenteral anti-schistosomal included: history of, or active therapy. Detection of HCV-RNA was infection with, Schistosoma mansoni, associated with a more severe liver sutures or abscess drainage, goza disease and occurred less frequently smoking in a group, and shaving by in patients with a history of community barbers. In the younger schistosomiasis (13). population risk factors were possibly In our series Bilharzial infection was related to circumcision. particularly associated with multiple valvular affection in females. In Prevalence of schistosomiasis in Ethiopia a community-based study Upper Egypt for S. haematobium from four endemic areas reported a ranges from 1.9% to 2.7% among the prevalence of 65.9% infected with communities and averages 8.9% in schistosoma with liver periportal endemic areas. Periportal fibrosis is thickening/fibrosis (PPT/F) in 4.6%. common together with hepatomegaly Similarly, 43.2% were positive for at and splenic enlargement . Risk factors least one marker of hepatitis B virus for infection are an age from 11 to 20; (HBV). Prevalence of PPT/F male gender; males bathing in, increased significantly with increasing women washing clothing or utensils community prevalence and intensity in, and children swimming or playing of S. mansoni infection. HCV was not in canals; and a history of, or associated with S. mansoni infection treatment for, schistosomiasis(11) or with schistosomal PPT/F (15). Other workers in Egypt(12) showed Also in our series presence of that the prevalence of S. mansoni in 5 Bilharsiasis with HCV was seen in 5 governorates in Lower Egypt, where cases, of whom 4 were females, again it is endemic, can average 36.4%. The with more severe cardiac disease and intensity of infection is highest in the malnutrition in the form of 10-14-year-old age group, Males overweight, increasing the possibility usually have higher infection rates of fatty liver. This is in agreement and ova counts than females in all age with another study in Egypt, where groups(12). Bilharzial liver showed higher Our series showed that multiple significant positivity of anti-HCV infections were common in 13 cases antibodies and insignificant decreased of whom 9 were females. Other level of zinc than negative ones. Fatty
84
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
liver cases showed higher statistically age groups were affected. A study in significant positivity of anti-HCV Romania showed that 50.7% of the 77 antibodies and chromium than children under 5 years old were negative ones. Hence having anti- positive for at least one hepatitis B HCV antibodies had a relation with virus marker, and 34.8% of fatty liver but not with aflatoxin and individuals aged 5-19 years with bilharzial liver more than having demonstrated seropositivity for HBsAg(16). Other workers have shown hepatitis B virus. 47% of adults from comorbidity of Schistosoma with the general population had at least one HCV positivity in Alexandria(17). marker for hepatitis B, 7.8% of However our findings contradict with pregnant women were seropositive for other workers in Upper Egypt where hepatitis B surface antigen, and 54.6% prevalence was higher among males of the infants aged 0-3 years living in than females (11.3% versus 6.5%; P < orphanages had at least one marker 0.001). Those who were less for hepatitis B(21). educated, farmed, provided health Since our group of subjects can be care, and were currently married had a considered high risk, we have significantly higher anti-HCV reviewed literature of comorbidities in prevalence than those who were not; other high risk groups. One study however, these associations were not showed the prevalence of HCV in significant after adjusting for age(18). high risk populations was 12.1% in Another study showed that although rural primary schoolchildren, 18.1% HBV-DNA in the serum was detected of residents of a rural village, 22.1% in 22.5% of anti-HBc-positive chronic of army recruits,16.4% of children HCV patients, it was not detected in with hepatosplenomegaly, 54.9% of any of anti-HBc-negative chronic hospitalized, multitransfused children, HCV patients. Hence Egyptian 46.2% of adults on hemodialysis, and chronic HCV patients have a high 47.2% of adults with chronic liver prevalence of occult HBV disease or hepatoma. Age-related infection(19). In Karachi, Pakistan, prevalence of anti-HCV in a random prevalence rates of HCV infection sample of 270 inhabitants of a rural rate was 3.3 % in the studied village increased progressively from population. Hepatitis HBsAg was zero in those 5-10 years of age to 41% more prevalent in subjects who in adults greater than the age of 50. received therapeutic injections despite There was increased prevalence of of using new needle and syringe and anti-HCV among children and adults vaccination in the government with parenteral exposures, however healthcare facilities. These factors the prevalence of anti-HCV among were not significant in anti-HCV persons representing the general positive cases(20). population of Egypt was also Age plays an important role in HCV strikingly high(22). Another study(23) infection, as our group showed that all reported that reported that among
85
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
groups working in tourism the subtypes 1b, 2a, and 3a, respectively. prevalence of HBV infection alone In conclusion, these results suggest was 20.7% and HCV infection alone that in Egypt, HCV along with was 7.4% and of markers for both schistosomal parasite infection is the HBV and HCV was 6.9%. None were major risk factor for chronic liver HIV positive. Primary residence in the disease. In most Egyptian patients, Nile delta and valley areas where HCV genotype 4 is highly prevalent schistosomiasis is highly endemic, and influences endemicity and disease was also a statistically significant risk prevalence in different region of the factor for HCV, but not HBV country (27,28,29). infection(23). The association between endemicity The prevalence of HCV infection of and nutritional factors as obesity has high risk groups especially of not been thoroughly investigated. hematologically multitransfused However with increased prevalence of patients varies from one center to obesity and overweight in our study another even in the same country group and its correlation with high depending on method used to assess blood pressure in our study groups, and regional endemicity, from a we presume that such findings may significantly high HCV positivity of influence the progression of the (81%) and HBsAg in (38%) to 41% disease. Other workers have shown a for HCV Ab by ELISA and 39% by correlation between overweight, RIBA method, and 29% for HBsAg obesity and hypertension and positive(24,25). consequent cardiovascular disease Also another study showed the risk to (30,31,32). be one in six among health workers The mechanism whereby co-infection but was more likely to be community with endemic diseases in RHD can acquired rather than occupationally influence the disease is not clear. The acquired. The prevalence of anti- RHD patients clearly had a depressed HCV, hepatitis B surface antigen cellular immune response to (HBsAg) and co-infection was 16.6%, streptococcal extracellular antigens(32). 1.5% and 0.2%, respectively. HCV- Moreover, peripheral blood RNA was present in 72.1% of anti- mononuclear cells from RHD patients HCV-positive health care workers and after exposure to a purified group A all but one subject were infected with streptococcal product generate HCV genotype 4(26). markedly greater than normal The possibility of genotypes linking cytotoxicity against a target that predisposition of such populations to displays differentiation antigens but such endemic diseases has been not major histocompatibility antigens investigated. In Egypt, HCV genotype on its surface(33). Cytokine play a role 4a is highly prevalent, where it in RHD activity as IL2 was shown to contributed 85% of the tested samples increase together with decrease in in comparison to 10, 2.5, and 2.5% for CD8 suppressor cells, with no change
86
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
in helper cells(34, 35). In hepatitis consider their liver disease state in cytotoxic T lymphocytes with CD8 order to improve its outcome. epitopes are the most important References effector cell population and the 1. Sani MU, Karaye KM, Borodo MM. immune defense seem to be (2007) Prevalence and pattern of suppressed by regulatory T cells(36). rheumatic heart disease in the Nigerian savannah: An echocardiographic Such findings indicate some degree of study.Cardiovasc J Afr. 18(5):295-9. synergism between the immune 2. Alkhalifa MS, Ibrahim SA, Osman SH. responses in RHD and hepatitis (2008) Pattern and severity of rheumatic cascading the predisposition to valvular lesions in children in Khartoum, Sudan.East Mediterr Health J. 14(5):1015- multiple co-infections and 21. predisposing to multiple valve 3. Carapetis J. Rheumatic heart disease in affection particularly on the right side developing countries.(2007) N Engl J of the heart. Liver cirrhosis and Med. 357:439-41. fibrosis may in return lead to further 4. Carapetis J, Steer A, Mulholland E, and Weber M. (2005) The global burden of deterioration of the RHD process and group A streptococcal disease. Lancet worsening of the prognosis. Infect Dis. 5:685-94.. Conclusions 5. Rayamajhi A, Sharma D, Shakya U. Comorbidity in RHD by Bilharsiasis, (2009) First-episode versus recurrent acute rheumatic fever: is it different?Pediatr Int. HBV, HCV can cause cirrhosis and 51(2):269-75. periportal fibrosis and thereby place 6. el-Nanawy AA, el Azzouni OF, Soliman additional burden on the heart by AT, Amer AE, Demian RS, el-Sayed causing hepatic dysfunction HM.(1995) Prevalence of hepatitis-C antibody seropositivity in healthy Egyptian contributing to increased right sided children and four high risk groups.J Trop pressure precipitating pulmonary Pediatr. 41(6):341-3. hypertension and tricuspid 7. Abdin ZH, Abul-Fadl MAM El-Fil S. regurgitation. On the other hand, (1970) Rheumatoid factor in cases of obesity and hypertension can affect rheumatic fever and parasitic infestation in children. Ann rheum. Dis. 29:660-662. the left side of the heart and increase 8. Abdin ZH, Eissa A. (1965) Rheumatic the risk of fibrotic changes in the fever and rheumatic heart disease in already affected valves. Comorbidities children below the age of 5 years in the are a potentially serious condition tropics. Ann Rheum Dis. 24(4):389–391. 9. Shrestha NR, Pilgrim T, Karki P, Bhandari when they present in RHD patients R, Basnet S, Tiwari S, Dhakal SS, Urban and every effort to detect them early P. (2012) Rheumatic heart disease and manage them before they cause revisited: patterns of valvular involvement hepatic disease should be sought. from a consecutive cohort in eastern Screening programs for early Nepal. J Cardiovasc Med (Hagerstown). 13(11):755-9. detection of subclinical carditis should 10. Okubo S, Nagata S, Masuda Y, Kawazoe also include screening for K, Atobe M, Manabe H.(1984) Clinical comorbidities. Moreover, screening features of rheumatic heart disease in patients exposed to surgery must Bangladesh.Jpn Circ J. 48(12):1345-9. 11. Gabr NS, Hammad TA, Orieby A, Shawky E, Khattab MA, Strickland GT.The 87
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
epidemiology of schistosomiasis in Egypt: 19. El-Sherif A, Abou-Shady M, Abou-Zeid Minya Governorate.Am J Trop Med Hyg. H, Elwassief A, Elbahrawy A, Ueda Y, 2000 Feb;62(2 Suppl):65-72. Chiba T, Hosney AM.(2009) Antibody to 12. El-Khoby T, Galal N, Fenwick A, Barakat hepatitis B core antigen as a screening test R, El-Hawey A, Nooman Z, et al. (2000) for occult hepatitis B virus infection in The epidemiology of schistosomiasis in Egyptian chronic hepatitis C patients.J Egypt: summary findings in nine Gastroenterol. 2009;44(4):359-64. governorates.Am J Trop Med Hyg. 2000 20. Jafri W, Jafri N, Yakoob J, Islam M, Feb;62(2 Suppl):88-99. Tirmizi SF, Jafar T, Akhtar S, Hamid S, 13. Angelico M, Renganathan E, Gandin C, Shah HA, Nizami SQ. (2006) Hepatitis B Fathy M, Profili MC, Refai W, et al. and C: prevalence and risk factors (1997).Chronic liver disease in the associated with seropositivity among Alexandria governorate, Egypt: children in Karachi, Pakistan.BMC Infect contribution of schistosomiasis and Dis 23;6:101. hepatitis virus infections. J Hepatol. 21. Paquet C, Babes VT, Drucker J, Sénémaud 26(2):236-43. B, Dobrescu A.(1993) Viral hepatitis in 14. Berhe N, Myrvang B, Gundersen SG. Bucharest. Bull World Health Organ. (2007) Intensity of Schistosoma mansoni, 71(6):781-6. hepatitis B, age, and sex predict levels of 22. Abdel-Wahab MF, Zakaria S, Kamel M, hepatic periportal thickening/fibrosis Abdel-Khaliq MK, Mabrouk MA, Salama (PPT/F): a large-scale community-based H, et al. (1994) High seroprevalence of study in Ethiopia.Am J Trop Med hepatitis C infection among risk groups in Hyg.77(6):1079-86. Egypt.Am J Trop Med Hyg. 1994 15. Bovet P, Yersin C, Herminie P, Lavanchy Nov;51(5):563-7 D, Frei PC. (1999) Decrease in the 23. Sayed HA, El Ayyat A, El Dusoki H, prevalence of hepatitis B and a low Zoheiry M, Mohamed S, Hassan M, prevalence of hepatitis C virus infections (2005) A cross sectional study of hepatitis in the general population of the Seychelles. B, C, some trace elements, heavy Bull World Health Organ. metals,aflatoxin B1 and schistosomiasis in 1999;77(11):923-8. a rural population, Egypt.J Egypt Public 16. el-Sayed NM, Gomatos PJ, Rodier GR, Health Assoc. 80(3-4):355-88. Wierzba TF, Darwish A, Khashaba S, 24. Said ZN, El-Sayed MH, El-Bishbishi IA, Arthur RR.(1996) Seroprevalence survey El-Fouhil DF, Abdel-Rheem SE, El- of Egyptian tourism workers for hepatitis Abedin MZ, Salama II.(2009) High B virus, hepatitis C virus, human prevalence of occult hepatitis B in immunodeficiency virus, and Treponema hepatitis C-infected Egyptian childrenwith pallidum infections: association of haematological disorders and hepatitis C virus infections with specific malignancies. Liver Int. 29(4):518-24. regions of Egypt.Am J Trop Med Hyg. 25. Mansour AK, Aly RM, Abdelrazek SY, 55(2):179-84. Elghannam DM, Abdelaziz SM, Shahine 17. Zaki A, Bassili A, Amin G, Aref T, Kandil DA,Elmenshawy NM, Darwish AM. M, Abou Basha LM.(2003) Morbidity of (2012) Prevalence of HBV and HCV schistosomiasis mansoni in rural infection among multi-transfused Egyptian Alexandria, Egypt.J Egypt Soc Parasitol. thalassemic patients.Hematol Oncol Stem 33(3):695-710. Cell Ther. 5(1):54-9. 18. Nafeh MA, Medhat A, Shehata M, Mikhail 26. Abdelwahab S, Rewisha E, Hashem M, NN, Swifee Y, Abdel-Hamid M, Watts S, Sobhy M, Galal I, Allam WR, et al. (2012) Fix AD, Strickland GT, Anwar W, Sallam Risk factors for hepatitis C virus infection I.(2000) Hepatitis C in a community in among Egyptian healthcare workers in a Upper Egypt: I. Cross-sectional national liver diseases referral centre.Trans survey.Am J Trop Med Hyg. 2000 Nov- R Soc Trop Med Hyg. 2012 Dec;63(5-6):236-4. Feb;106(2):98-103. 88
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
27. Halim AB, Garry RF, Dash S, Gerber immune responses to extracellular MA.(1999) Effect of schistosomiasis and streptococcal products in rheumatic heart hepatitis on liver disease. Am J Trop Med disease.J Clin Invest. 1981 Sep;68(3):665- Hyg. 60(6):915-20. 71. 28. Kamel MA, Miller FD, el Masry AG, 33. Regelmann WE, Ernest D Gray ED, Zaher Zakaria S, Khattab M, Essmat G, Ghaffar S, Kamel , Aziz El Kholy A, Abdin Z and YA.(1994) The epidemiology of Monsour M. (1987) Cytotoxic Schistosoma mansoni, hepatitis B and Lymphocyte Activity in Rheumatic Heart hepatitis C infection in Egypt.Ann Trop Disease (RHD) Pediatric Research. 21, Med Parasitol. 88(5):501-9. 317A–316A. 29. Habib M, Mohamed MK, Abdel-Aziz F, 34. Zedan M., ElShenawy F., Abou Bakr HM, Magder LS, Abdel-Hamid M, et al.(2001) Al-Basousy AM. (1992) nterleukin-2 in Hepatitis C virus infection in a community relation to T cell subpopulations in in the Nile Delta: risk factors for rheumatic heart disease. Archives seropositivity. Hepatology. 33(1):248-53.4 ofDisease in Childhood 1992; 67: 1373- 30. Hourigan L, Macdonald G, Purdie D. 1375. Fibrosis in chronic hepatitis C correlates 35. Miller LC, Gray ED, Mansour M, Abdin significantly with body mass index and ZH, Kamel R, Zaher S, Regelmann steatosis. Hepatology, 1999, 29:1215- WE.(1989) Cytokines and 1219. immunoglobulin in rheumatic heart 31. Rostom S., Mariam Mingit Lahlou R., disease: production by blood and tonsillar Hari A., Bahiri R., Hajjaj-Hassouni N et al mononuclear cells.J Rheumatol. 1989 (2013) Metabolic syndrome in rheumatoid Nov;16(11):1436-42. arthritis: case control study. 36. Dienes HP, Drebber U.(2010) Pathology Muscloskeletal disroders14:147. of immune-mediated liver injury.Dig Dis. 32. Gray ED, Wannamaker LW, Ayoub EM, 2010;28(1):57-62. el Kholy A, Abdin ZH.(1981) Cellular
MR+PR, 2.5 MR+TR, 2.5 MS, 2.5 MR+AR, 18
MS+MR, 5 MR, 72.5
Figure 1: Distribution of rheumatic heart patients by valvular affection
89
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
2.5 2-5 years 17.5 20 6-11 years 12-18 62.5 years
Figure 2: Frequency distribution of rheumatic heart patients of studied sample by age group.
Co-morbidities in RHD patients 45 30 50 22.5
0 HBV HCV Bilharziasis
Figure 3: Frequency distribution of endemic diseases as hepatitis B virus, hepatitis C and Bilharzia among patients diagnosed with rheumatic heart disease.
50 20 22.5 25 10
0 Systolic BP > 90 Diastolic BP > 140Overweight (BMI>24)Obese (BMI>33)
Figure 4: Frequency distribution of hypertensive disease, overweight and obesity among patients diagnosed with rheumatic heart disease.
90
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Femal 100 es 25 Males 80 55 75 60 80 40 75 45 20 0 BMI <14 BMI 15-24 BMI >24 BMI >33 Figure 5: Distribution of overweight and obesity by gender
100 80 66.7 69.2 60 75 40 Females 33.3 20 30.7 25 Males 0
Figure 6: Distribution of prevalence of co-morbidities by gender
100%
Females 50% Males
0% Normal Borderline High
Figure 7 a: Distribution of the diastolic blood pressures ranges by gender
91
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
100% 80% 60% Females 40% Males 20% 0% Normal Borderline High
Figure 7 a: Distribution of the systolic blood pressures ranges by gender
HBV+HCV+Bilh
HCV+Bilh
HBV + Bilh
HBV+HCV
HVC
HBV
Bilh.
0 50 100 150
Females Males
Figure 8: Frequency distribution of rheumatic heart patients with multiple affections of endemic diseases by gender.
92
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
تأثٌر الفوارق بٌن الجنسٌن والمراضة المشتركة على نمط مرض روماتٌزم القلب فً مصر أ.د/ عضة أب٘ اىفعو ، د / عالء اىغَشاٛٗ ، د/ ٕشبً اىششٝف
هنه دراسة منبثقة من مشروع REMEDY الني تم بالتعاون مع جامعة كٌب تاون فً جنوب أفرٌقٌا
______الخلفٌةة: لورد حردث تريير فر نىرط ىر ىر تيزم الولرب علر ىرد العور د الى ضرية علر الرر غم ىررن إنخفرر اإلصرر بة بهررذا الىرر إال أن األبررب ب الىصرر حبة ألنىرر ط الترييرر غيرر ىفه ىة. ىو إنتش األى ا الىبت طنة البله زي الته ب الابد ب ج ا تف ضرط الدم البىنة فإن البد ىن د ابة تسثي ذه الع اى عل نىط ذا الى . الهةةد : تويرريم ىررد انتشرر األىرر ا الىبررت طنة برر ً الترذيررة فرر الررذين يعرر ن ن ىررن ىرر ى تيزم الولب تسثي ذل، عل نىط الى . المنهجٌةةة تررم تجىيررو 45 ىرر ي ب ىرر تيزم الولررب ىررن ى اررز أىرر ا الولررب ال ى تيزىيررة ب لىحلة الاب بىح فظة الر بية . قد تع الى ض للتشخي ب لى جر فر ق الصر تية بررحب عينرر الرردم للاشرر عررن األجبرر م الىضرر دة إللتهرر ب الابررد البرر ئ إختبرر ا للفيرر الابد "ب" االختب ا ال تينية للاش عن البله زي ف البر البر از، ىرو قير ىاشر اتلة الجبم ىن ال زن الط ضرط الدم. النتةا: ت ا حرر األعىرر ىرن 5.5 إلرر 23 ع ىرر ، اىر ا نرر نبرربة اإلنر ث إلرر الررذا ارر ن 53:52. ا ن غ لبية الح ال إ تج ف الصى م الىيت ال ف 12.5٪ تليه ىجتىعة إ جر فرر الصررى م الىيت الرر األ ترر فرر 22.5٪. ا نرر االختبرر ا الىصررلية إيج بيررة لفيرر )برر فرر 45٪، 22.5٪ للبرر ئ البله زيرر فرر 35٪ ، قررد زاد اإلنتشرر بشررا ىلحرر ظ فرر اإلن ث ى تين أاث ىن الذا . ار ن االعرتال الىشرت ، أاثر شري ع فر اإلنر ث ار ن ى تبطر ب جرر د إخررتال فرر صررى ى ىتعررددة. قررد ترر ا م ىاشرر اتلررة الجبررم 24-42 ارر ن شرر ئع فرر اإلن ث ا ن ى تبط ىو ى صى ى ىتعددة ىو الضرط الى تفو البىنة. االسةةتنتاجات: االعررتال الىشررت ، ىررو أىرر ا الىبررت طنة شرر ئو بررين ى ضرر ىرر تيزم الولررب ب ألخ ف الذين يعيشر ن فر الىنر طق الى بر ًة، بر ألخ برين اإلنر ث. الرذين يعر ن ن ىرن ب ً الترذية نتيجة زي دة ال زن. لذل، ت ص الد ابرة ب جر د ح جرة لبر اى ق ئيرة لى اجهرة األى ا غي الىعدية ف إط نه ىتا ى ش ى ىو األخرذ فر اإلعتبر أ جر التفر برين الجنبين صحة الى ا وين. ______
93
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
Role of International Certified Lactation Consultants in Making Hospitals Baby Friendly Azza Abul-Fadl MD, IBCLC, Mohga Fikry PHD, IBCLC, Naneis Abdel Mohsen, IBCLC, MCH/MoH, IBCLC, Samaah Zohair, IBCLC, Enas ElShabrawi, MSc Ped., IBCLC ______International Certified Lactation Consultants (IBCLCs) are specialists in lactation management and infant feeding that become certified after sitting for an international exam organized by the International Board of Lactation Consultant Examiners (IBLCE) in Virginia, USA. The exam site is present in over 52 countries and has been involved in qualifying and recertifying thousands of IBCLCs all over the world(1). This has created a profession that is so much needed by mothers and has resulted in improved clinical management and research in this field. In the past decades there has been a resurgence of breastfeeding practices that had declined progressively since the marketing of infant milk formula and shift from breastfeeding to bottle feeding. Global community awakening to the need for this practice was brought about by the gravity of the rising burden of disease from poor infant feeding practices that has caused millions of babies in developing countries to die as a result of communicable disease. Still decades later as presently seen, millions of others are suffering the toll of non- communicable disease in both developed and developing countries. The disease burden has caused expenditure on health care to rise and this can impede development and devastate the economy, by incapacitating its human resources and depleting its financial resources. Despite all efforts of international and independent organizations to control the effects of aggressive marketing and poor practices of food industry, the alterations it has caused across generations may take centuries to reverse. Strategies adopted by international organizations included the adoption of the International Code of Marketing of Breast milk Substitutes (ICMBMS) by the general assembly of the World Health organization in 1981 and this was followed up be series of subsequent resolutions to protect infant and young child feeding practices (2). Today there is a shift of the pattern of malnutrition caused by these artificial milks and marketed baby foods from wasting and underweight from repeated diarrheas and poor nutritional practices, to obesity and long term non- communicable disease in both underdeveloped and developed countries. IBCLCs are internationally recognized professionals, qualified to help mothers make an informed decision about feeding their babies in order to provide them with state of the art care about feeding and nurturing their offsprings and protect 94
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
them from being lead by the marketing tactics and the prevailing misconceptions they create. Unfortunately many mothers continue to fail to give the best start in the life for their babies, despite the efforts of IBCLCs. The challenges are many and we can discuss but few(3). A leading cause for the rapid change in practices towards bottle feeding was the adoption of IMF feeding by the medical organization from birth. Up to this day, many pediatricians are in close alignment with IMF companies, being their primary support agents for ensuring that distribution of their product, despite its proven evidence based hazards. The medical profession has been distracted by these marketing hustlers who have no medical background, but are simply seeking profit from a business they claim to be for the welfare of children. Although these products are not foods but medicine for these babies deprived of motehr's milk, yet even pharmaceutical organizations do not recognize them, except for a few exceptional products for metabolic conditions that are not profit making for them as it is simply another gimic of industry! The same industry that has manipulated many other nutrition products with the pretense of being for the welfare of people, yet they are actually the cause of doom to mankind(4). In the realm of these emerging events that have changed the face of medical conditions that we deal with, industry has corrupted our health and the health of our babies for generations to come with no regard for the future of the world. Among the global initiatives to bring an end to this disaster set ahead by industry, the Baby friendly Hospital Initiative (BFHI) was introduced. It was based on the adoption of Ten Steps to ensure successful breastfeeding begins in hospitals without interference of industry (3,5). The tool is merely an informational and educational tool for empowering health staff to stand up to the marketing vampires of industry and in same time empower mothers and their families to make an informed choice about feeding their babies by increasing their awareness of the hazards of formula feeding, the effects it has on making a decision on feeding her baby and the skills, techniques and practices they need to learn in order to prevent them from falling as bait to the industrial schemes. The introduction of the BFHI was a breakthrough for the IBCLCs to be regarded as having a potential role in making this initiative work in the health care system(6). Unfortunately IBCLCs, have not been recognized by the health care system or medical profession as being an integral part of their team. To this day many countries have not introduced this field as a subspecialty in their higher education curricular outlines and specialties. The IBLCE remains the sole independent organization that qualifies professionals coming from different educational backgrounds to become certified lactation consultants. Its presence in the house of all industry, in the USA, has limited their international
95
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
dissemination, but has on the other hand made them powerful through their regional offices all over the world. These offices have played a significant role in enhancing the effectiveness of IBCLCs and their dissemination throughout the world. Currently, the World Health organization (WHO) recognizes IBCLCs as state of the art professionals in infant and young child feeding and urges governments to use them as best possible they can. This was released in the Global Strategy for Infant and Young Child feeding in 2003(6,7). In Egypt, recently, the Ministry of Health adopted the National BFHI program and has piloted its implementation by Baby friendly Districts, by making hospitals and nearby maternal and child Health centers (MCHs) and the surrounding community Baby Friendly. Six such districts were started in Damitta city in Damitta, Ismailia city in Ismailia, kafr Shoukr district in Kaluibiya, Nagh Hamadi district in Qena, Maragha district in Sohag and Fayoum district in Fayoum governorates and Gharb region in Alexandria. Our experience with BFHI as Mother and Child care Association (MCFC) has shown that IBCLCs can make a difference in instigating change. However because of their low profile and the limited marketing of this profession, the lack of recognition by the health authorities as a profession, but rather as experts who have professional expertise, has isolated them from the general population. The IBCLCs in MCFC worked with the national BFHI program, supported by UNICEF, to identify community resources that could support dissemination, but because they themselves were not recognized by the medical syndicate or health authorities as professionals and key members in the health care team for caring for mothers and babies, they were marginalized and hence their purpose was undermined, although it could have achieved much better success stories. One of the major success stories in the national program of the BFHI in Egypt was that IBCLCs were appointed by the local health authority in Damietta general hospital and Ismailia general hospital as focal persons or coordinators for BFHI in the hospital. However this was not in their job description neither were they paid for it, but despite this, their input was significant in making change in their facility. Unfortunately they were neither promoted nor acknowledged for their efforts, and they were not even expecting this, and did what they did as in-kind services in their positions in the facility. Another success story was in Alexandria where the coordinator in the MoH in Alexandria was an IBCLC and this resulted in a dramatic success in the implementation of BFHI in the region. While in health facilities lacking in this kind of professional expertise, the implementation of BFHI was aborted once the program was withdrawn from the funding, as was seen in the other locations as Kaluibiya, Fayoum, Qena and Sohag. In the latter, an IBCLC was trying to get footage into the program and give her expertise to the health authorities but they refused to utilize her as a coordinator, as a result the implementation
96
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
process in Maragha, Sohag has come to an arrest. This has also happened in Fayoum, where IBCLCs working in the university, were not recognized by the health professionals as potentials for become coordinators for the program in their region. The lessons learnt from these interventions show that there is a need to recognize and acknowledge specialties linked to national programs and that institutionalization of programs into the Ministries of health cannot be successful unless educational systems also adopt and qualify professionals that can feed into these programs. Furthermore administration authorities need to recognize these professionals as advocates and not competitors to their work. In conclusion, lactation consultants in the country need to be recognized and given their full potential to prove that they can make change as they play a vital role in the long term strategic input for the prevention and control of non communicable disease(9). Other countries have shown that breastfeeding support through IBCLCs are greatly needed and can improve maternal and infant outcomes in hospitals and primary health care(10,11). This can only be achieved when the educational system in the country works towards supplying professionals and specialists with degrees that meet the country needs of the health service delivery systems (11). Currently an effort to accredit educational institutions is on the rise; this could be an opportunity to seize to make the change and invest in expanding and integrating newer dimensions in health care. IBCLCs integration in the health care system as a profession and in the educational system as a specialty can greatly improve maternal child health outcomes(11). References 1. International Board of Lactation Consultant Examiners (IBLCE), http://www.iblce.org/ 2. World Health Organization (1981): International Code of Marketing of Breast-Milk Substitutes endorsed by the Executive Board of the World Health Organization at its sixty -seventh session, Geneva. 3. Evidence for the Ten Steps to Successful Breastfeeding WHO/CHD/98.9 Geneva, World Health Organization. 1998. Available in English, French and Spanish. 4. Environmental and Health Risks Associated with Infant Formula. http://www.momsandpopsproject.org/formula.php 5. UNICEF/WHO (2009) Baby-friendly hospital initiative: revised, updated and expanded for integrated care. (2009) Produced by the World Health Organization, UNICEF and Wellstart International, Geneva. 6. International Board Certified Lactation Constant: International Lactation Consultant Association (ILCA), http://www.ilca.org. 7. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding. Geneva, World Health Organization, 2003. Full text in PDF in English, Arabic, Chinese, French, Russian, Spanish. 8. WHO/UNICEF. Implementing the Global Strategy for Infant and Young Child Feeding: Report of a technical meeting. Geneva, World Health Organization, 2003. 9. Castrucci BC, Hoover KL, Lim S, Maus KC.(2006) A comparison of breastfeeding rates in an urban birth cohort among women delivering infants at hospitals that employ and do not employ lactation consultants.J Public Health Manag Pract.12(6):578-85. 10. Powell D et al. (2011) International board certified lactation consultants are needed from every background. J Hum Lact. 27(1):13 11. Thurman SE, Allen PJ.(2008) Integrating lactation consultants into primary health care services: are lactation consultants affecting breastfeeding success?Pediatr Nurs. 34(5):419-25. 97
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
دٗس اإلسحشبسٜٝ اىَعحَذ ٍِ ٕٞئة اىشظبعة اىطثٞعٞة اىعبىَٞة فٜ خعو اىَسحشفٞبت صذٝقة ىيشظع زٌذوٛؽسظ /عضظ أضٛ زٌفعً – زٌذوٛؽسظ / ٔس١ٔظ عطذ زٌّىغٓ – زٌذوٛؽسظ / ِٙمع فىشٞ - زٌذوٛؽسظ/ عّسن ص١٘ش – زٌذوٛؽسظ /ج٠ٕسط ٛؼف١ك زٌكطشزٞٚ ______زيعؽكددسس١٠ٓ زٌددذ١١ٌٚٓ فددٟ زٌشظددسعع ٘ددُ ؽِخصصددْٛ فددٟ ِمددسي جدزسظ زٌشظددسعع ؼٚغز٠ددع زٌشظع ِةؽّذ٠ٓ ِٓ لطً ز١ٌٙرع زٌذ١ٌٚع ؽٌّّى١ٕٓ زعؽكسسٞ زٌشظدسعع )IBLCE( زٌٛزلةدع فٟ فٚ ٟي٠ع فشل١ٕ١س، ضسٌٛي٠سغ زؽٌّىذظ زألِش٠ى١دع. ؽ٠ٚمدذَ ٌمؽِىدسْ ٌٍىصدٛي عٍدٝ ٘دزٖ زٌكٙسدظ زٌّرسغ ِٓ ضالد ِخؽٍفع فٕٙسن ز٢يف ِٓ زإلعؽكسس١٠ٓ زٌدذ١١ٌٚٓ فدٟ زٌشظدسعع فدٟ ل١ّع أٔىسء زٌةسٌُ. ٚلذ أدؼ ٜذٛ٘س ِّسسزعسغ زٌشظسعع زٌطط١ة١ع فٟ زٌةمدٛد زٌّسظد١ع جٌدٝ خٍدك وسلدع ِسعدع ٛؽٌلدٗ ِٚغدسٔذظ زألِٙددسغ ١ؽٔمدع جٔخفددسض ِةدذيغ زٌشظددسعع زٌطط١ة١دع عٍددٝ أـدش زؽٌغدد٠ٛك زٌمسذش ِدٓ لطدً شدشوسغ زٌٍدطٓ زٌصدٕسعؽٌّٕ ٟمدسٚ ُٙؼزؽٌىدٛي ِدٓ زٌشظدسعع زٌطط١ة١دع جٌدٝ زٌشظسعع زٌصٕسع١ع ٚفٟ خعْٛ صىٛظ زٌةسٌُ ٌٙدزٖ زٌّّسسعدسغ ٚ ضخطٛسؼدٗ ٚخصٛصدس عٕددذِس ؼددٛفٟ زٌّال٠دد١ٓ ِددٓ زألغفددسي فددٟ زٌطٍددذزْ زٌٕس١ِددع ١ؽٔمددع ٌألِددشزض زٌغددسس٠ع ٚعددٛء زؽٌغز٠ددع زؽٌددٟ صددسوطػ ٘ددزٖ زٌّّسسزعددسغ ٚ ِددٓ ـددُ ِشزظددع ٚٚفددسظ ِال٠دد١ٓ خددش٠ٓ ضغددطص زألِددشزض غ١ددش زٌغددسس٠ع عددٛز ء فددٟ زٌطٍددذزْ زؽٌّمذِددع أٚزٌطٍددذزْ زٌٕس١ِددع. ِٚددع ٛؼزصددً عددذد زٌّصسض١ٓ ِٓ عصء ٘زٖ زألِشزض ٚزإلٔفسق عٍدٝ زٌشعس٠دع زٌصدى١ع ٌٙدس ٚزؽٌدؽؼ ٟغدطص فدٟ جعسلددع ١ّٕؽٌٍددع ٚج١ٙٔددسس ٌاللؽصددسد، ِددٓ خددالي ؼةم١ددض ٌٍّددٛزس زٌطكددش٠ع ٚزعددؽٕضزف ٌٍّددٛزسد زٌّسد٠ع. ؼٚغؽّش ٘زٖ زٌّأعسظ عٍٝ زٌشغُ ِٓ لٙدٛد زٌّٕاّدسغ زٌذ١ٌٚدع ٚزٌمّة١دسغ زٌّى١ٍدع فٟ ٔكش زٌدٛعٟ دزخدً زٌّمؽّةدسغ عدٓ ِخدسغش ٘دزٖ زٌّّسسزعدسغ ٚأ١ّ٘دع جعدؽشلسع ـمسفدع زٌشظسعع زٌطط١ة١ع . ٚلذ شػٍّ زيعؽشز١ؼم١سغ ِٓ لطً زٌّٕاّسغ زٌذ١ٌٚع جعالْ ؼٚطٟٕ زٌّذٚٔع زٌذ١ٌٚدع ؽٌغد٠ٛك ضذزذً ٌطٓ زألَ ِٓ لطً زٌمّة١ع زٌةسِع ٌّٕاّع زٌصدىع زٌةس١ٌّدع فدٟ عدسَ ؼٚ 0860طدع ٘دزز عٍغٍع ِدٓ زٌمدشزسزغ زٌالومدع ٌىّس٠دع ِّسسعدسغ ؼغز٠دع زٌشظدع ٚصدغسس زألغفدسي )ِٕاّدع زٌصىع زٌةس١ٌّع، 0860(. ِٚددٓ ضدد١ٓ زٌّطددسدسزغ زٌةس١ٌّددع ٌٛظددع وددذ ٌٙددزٖ زٌىسسـددع ٘ددٝ ِطددسدسظ زٌّغؽكددف١سغ زٌصددذ٠مع ٌألغفسي ٚزؼ ٟؽٌٕسدٞ ضأْ ؼططك زٌّثعغسغ زٌصى١ع زؼ ٟؽٌمذَ خذِسغ ٌألَ ٚ زٌطفدً زٌةكدش خطٛزغ ٌعّسْ ٔمسن زٌشظسعع زٌطط١ة١ع زؽٌدؼ ٟطدذأ ِدٓ فؽدشظ سعس٠دع زٌىسِدً جٌدٝ خدشٚق زألَ ِٓ زٌّغؽكفؽِٚ ٝسضةٙؽس ضسٌّغسٔذظ ضةدذ عٛدٙؼدس ٌٍط١دٚ ػضدذؼ ْٚدذخً ِدٓ زٌمٙدسغ زؽٌدٟ ؼصددٕع ؼٚددٛصع زؽٌّٕمددسغ زٌطذ٠ٍددع. ٚ٘ددٟ أ٠عددس ِطددسدسظ عس١ٌّددع ؽٌّىدد١ٓ زٌةددس١ٍِٓ فددٟ ِمددسي زٌصىع ؽٌٍصذٞ فٚ ٟلٗ زإلعؽٕضزف زٌمدسذش ٌّصدٕةٚ ِٟدٛصعٟ ٘دزٖ زٌطدذزذً ٚفدٟ زٌٛلدػ ٔفغٗ ؼّى١ٓ زألِٙسغ ٚعسذالٙؼُ يؼخسر لشزس ِغ١ٕؽش وٛي ؼغز٠ع أغفسٌٙٓ عٓ غش٠ك ص٠دسدظ ٚعددٙ١ُ ضّخددسغش زؽٌغز٠ددع زٌصددٕسع١ع ، ٚ ـددسس رٌدده عٍددٝ زؼخددسر لددشزس ضكددأْ ؼغز٠ددع غفٍٙددس
98
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
ٚزٌّٙسسزغ ٚزؽٌم١ٕسغ ٚزٌّّسسعسغ زؽٌدٟ ضىسلدع جٌدٝ أْ ٔدؽةٍُ ِدٓ ألدً ِدٕةُٙ ِدٓ زٌٛلدٛع وطةُ ٌّخططٟ زٌةس١ٍِٓ فٟ ِمسي صٕسعع زألغز٠ع ٌٍشظع. ٚفٟ ِصش، فٟ زٚ٢ٔع زألخ١شظ، زعؽّذغ ٚصزسظ زٌصىع زٌطشٔسِك زٌمِٟٛ ٌّطسدسظ زٌّٕكدتغ زٌصى١ع زٌصذ٠مع ٌألَ ٌٍٚطفً ؼ ػّؼٚمشضؼٚ ٗؽٕف١زٖ ِٓ خالي زٌّٕسغك زٌصدذ٠مع ٌألغفدسي، ضمةددً زٌّغؽكددف١سغ ٚوددذزغ ِشزوددض سعس٠ددع زألَ ٚزٌطفددً ٚضددسلٟ زٌّمؽّددع زٌّىددٚ ػ١د٠ددع أٞ صددذ٠مع ٌٍشظددع ٚأِٙددسٚ ُٙؼلددذ ضددذأ زؽٌطط١ددك ضسٌفةددً فددٟ ِذ٠ٕددع د١ِددسغ ضددذ١ِسغ، ِٚذ٠ٕددع زإلعّسع١ٍ١ع ضسإلعّسع١ٍ١ع، ِٚشودض وفدش شدىش فدٟ زٌمٛ١ٍض١دع، ِٚىدض ٔمدع وّدسدٞ ضّىسفادع لٕددس، ِٚشوددض زٌّشزغددع فددٟ عددٛ٘سق ِٕٚطمددع زٌف١ددَٛ فددٟ ِىسفاددسغ زٌف١ددٚ َِٕٛطمددع زٌغددشش ضسإلعىٕذس٠ع. ٚلددذ أوٙددشغ ؼمشضؽٕددس ِددع ٌّطددسدسظ زٌّٕكددتغ زٌصددى١ع زٌصددذ٠مع ٌددألَ ٌٍٚطفددً أْ ٚلددٛد زإلعؽكددسس١٠ٓ زٌددذ١١ٌٚٓ فددٟ زٌشظددسعع ضسٌّٕكددأظ ٠ّىددٓ أْ ٠ىددذؾ فشلددس فددٟ زؽٌىددش٠ط عٍددٝ زؽٌغ١١ش. ٌٚىٓ ضغطص زؽٌغ٠ٛك زٌّىذٚد ٌٙزٖ زٌّٕٙع، ٚعذَ زيعؽشزف ضٙس ِدٓ لطدً زٌغدٍطسغ زٌٕمسض١ع زٌصى١ع وّٕٙع صى١ع، ٚزإلعؽةسٔع ضُٙ وّمدشد خطدشزء فمدذ أدٜ رٌده جٌدٝ زٌىدذ ِدٓ ؼأـ١شُ٘ ضسٌّمؽّع ٚعضٌُٙ عٓ عسِع زٌغىسْ. ٚلذ أدٜ رٌه ج١ّٙؼ ٌٝش دٚس٘دُ ضدسٌّمؽّع ، عٍددٝ زٌددشغُ ِددٓ أٙٔددُ وددسٛٔز ٚسزء لصدد زٌٕمددسن زٌشذ١غدد١ع فددٟ زٌطشٔددسِك زٌمددِٟٛ ٌّطددسدسظ زٌّٕكتغ زٌصى١ع زٌصذ٠مع ٌألَ ٌٍٚطفً فٟ ِصدش فمدذ ؼدُ ؼة١د١ٓ زألعؽكدسس١٠ٓ زٌدذ١١ٌٚٓ فدٟ زٌشظدددسعع ِدددٓ لطدددً زٌغدددٍطسغ زٌصدددى١ع زٌّى١ٍدددع فدددٟ زٌّغؽكدددفٝ زٌةدددسَ ضّغؽكدددفٝ د١ِدددسغ ٚزإلعّسع١ٍ١ع زٌةسَ وأشخسص ؽٌٍٕغ١ك ؽٌٍطط١ك زٌطشٔدسِك زٌمدِٟٛ دزخدً زٌّغؽكدف١سغ ٚ ٌىدٓ ٘زز ٌُ ٠ىٓ ظّٓ زٌٛص زٌٛو١فٟ أٚ ِىذد ٌٗ ألش ، ٌٚىٓ عٍٝ زٌشغُ ِٓ ٘زز، فمدذ ودسْ جعٙسُِٙ ِثـش فٟ جوذزؾ زؽٌغ١١ش فٟ ِشزفمٚ .ٌُٙألع ٌُ ٠ةؽشف ضمٛٙدُ٘، فمدذ فةٍدٛز ِدس فةٍددٛز ضددززٙؼُ ِددٓ خددالي وددُٙٔٛ جخصددسذ١١ٓ أغفددسي أٚ ٔغددسء ١ٌٛؼٚددذ فددٟ ِددٛزلةُٙ ضددسٌّشزفك زٌصى١ع. ؼٚىشسغ لصع ٔمسن أخشٜ فدٟ زإلعدىٕذس٠ع و١دؿ ودسْ ِٕغدك زٌطشٔدسِك ضّذس٠دع شرٚ ْٛصزسظ زٌصىع ضسإلعىٕذس٠ع وسصدً عٍدٝ زٌكدٙسدظ زٌذ١ٌٚدع ١ٌٙردع زٌشظدسعع ٚلدذ أدٜ ٘زز جٌٝ زٌٕمسن زٌىط١ش فؼ ٟٕف١ززٌطشٔسِك فٟ زٌّٕطمع. ض١ّٕس فٟ زٌّشزفدك زٌصدى١ع زؽٌدؼ ٟفؽمدش جٌٝ ٘زز زٌٕٛع ِٓ زٌخطشزغ ز١ٌّٕٙع فمذؼُ جوطسغ ؼٕف١ز زٌطشٔسِك ضّمشد عىص ز٠ّٛؽًٌ، ؼٚاٙددش ٘ددزٖ زؽٌمشضددع أْ ٕ٘ددسن وسلددع ٍِىددع ٌالعؽددشزف ٚزإللددشزس ضسؽٌخصصددسغ زٌّشؼططددع ضطشزِك ل١ِٛع ٚوزٌه ٠مص زعؽّسد٘س ِٓ لطً زٌٕاُ زؽٌة١ّ١ٍع ؼٚأ١ً٘ ز١١ٌّٕٙٓ زٌدز٠ٓ ٠ّىدُٕٙ زٌةًّ فٟ ٘زٖ زٌطشزِك. ٚعالٚظ عٍٝ رٌه ٠مص عٍٝ زٌغٍطسغ أْ ؼةؽشف ضٙدثيء ز١ٌّٕٙد١ٓ ٚجدخسي ِغٚ ّٝو١فع ٌُٙ ضسٌمٙسص زٌصىٟ. ٚفٟ زٌخؽدسَ، فدٕىٓ ٛٔصدٟ ضأ١ّ٘دع زإلعؽدشزف ضّٕٙدع زيعؽكدسس١٠ٓ زٌدذ١١ٌٚٓ فدٟ زٌشظدسعع ؼٚددٛف١ش زٌّٕٙم١ددع زٌغ١سعدد١ع ٚزإلدزس٠ددع ٌمعؽددشزف ضسٌّٕٙددع ٚسضطٙددس ضىددٛزفض جدزس٠ددع ِٚسد٠ددع ٌخٍدك غٍدص عٙ١ٍددس ؼ ٚدٛف١ش زٌّٕدسي زٌةٍّددٚ ٟزؽٌة١ٍّدٟ إلـطدسغ رزٙؼددُ ١ّٕؼٚدع لدذسزٚ ُٙؼرٌدده وحعددؽشز١ؼم١ع غ٠ٍٛددع زٌّددذٜ ٌٕكددش زٌطشٔددسِك زٌمددِٟٛ فددٟ وسفددع أٔىددسء زٌّٕكددتغ زٌصددى١ع ضسٌمّٛٙس٠ع ٚظّسْ جعؽّشزسٙؽ٠س ٚفسعٙؽ١ٍس.
99
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
الروح و الجسد و النفس فى االسالم ______زئغددسْ زٌددزٜ فطددشٖ ى ؼةددسٌٝ ؽ٠ىددْٛ ِددٓ ـالـددع أشدد١سء: زٌددشٚن ٚ زٌمغددذ ٚ زٌددٕفظ. ف١ّس ٍٝ٠ عٛف ؽٔةشف عٍٝ ِةٕٝ وً ٚزودذ ِدٚ ُٕٙ ِدذٜ زسؼطسغدٗ ضدس٢خش ؼٚدأـ١شٖ ع١ٍٗ. ٚ عٕطذأ ضسٌشٚن. وٍّس زؽٌضِٕس ضسؽٌةس١ٌُ زٌذ١ٕ٠ع وسٌصالظ ٚزٌصٚ َٛ زخالل١سغ زيعدالَ وسألِش ضسٌّةشٚف ٚزٌٕٝٙ عٓ زٌّٕىدش وٍّدس عدّٛٔس ضدسٌشٚن ٚزسؼم١ٕدس ضٙدس زٌدٝ ِٕضٌدع زٌّالذىع. ٚعٍٝ زٌةىظ وٍّس ٌُ ؽٍٔضَ ضسٌةطسدزغ ٚ زألخالل١سغ ٚ ٔشلدٝ ضسٌشٚوس١ٔدسغ وٍّس ؼذ١ٕٔس ضسٌشٚن زٌٝ ِشزؼص زٌك١سغ١ٓ ٚزٌىٛ١زٔسغ.أِس زٌمغدذ فٙدٛ ٍِّدٛط ٌٚد١ظ ِىغٛط وسٌشٚن. فدسٌشٚن ي ٠ّىدٓ ستٙؽ٠دس أٚ ٌّغدٙس ٚ ٌىدٓ ٠ّىدٓ زيوغدسط ضٙدس. أِس زٌمغذ فٛٙ ِشذٍِّٛ ٚ ٝط. ففٝ زإلعالَ ٕ٘سن أش١سء ٠ّىٓ أْ ٔفةٍٙس ضمغذٔس وسٌةًّ ٚ زٌصالظ ٚ ٕ٘سن ِىشِسغ ي ٠ّىٓ أْ ٔفةٍٙس ضمغذٔس. ٚ ٕ٘سن ؼأـ١ش ٌٍدشٚن عٍدٝ زٌمغدذك فىٍّدس ؼصدفؼ ٚ ٛشلدٝ زٌشٚن وٍّس زوغغٕس ضشزوع فٝ زٌمغذ ٚ ٘ذٚء ٔفغٝ. أِس عدٓ زٌدٕفظ فٕٙدسن ـالـدع زٔدٛزع ٚ ٘دُ زٌدٕفظ زألِدسسظ ضسٌغدٛء ٚ زٌدٕفظ زٌٍٛزِدع ٚ زٌٕفظ زٌّطّرٕع. زٌٕفظ زألٝ٘ ٚ ٌٝٚ زألِسسظ ضسٌغٛء ؼدأِش زئغدسْ ضفةدً زٌّةسصدٝ ٚ زٌّٕىشزغ. أِس زٌٕفظ زٌفس١ٔع ٝ٘ ٚ زٌٍٛزِع ٍٛؼَ زئغسْ عٍدٝ فةدً أٜ خطدأ ٠ّىدٓ فةٍٗ فؽغطص ٌمٔغسْ وسٌع ِٓ زٌٍَٛ ٌٍٕفظ ؼ ٚكمةٗ عٍٝ عذَ زسؼىسش أٜ فةً خطأ خطشضطسٌٗ. أِس زٌٕفظ زٌّطّرٕع فٝٙ زٌٕفظ زٌّغؽمشظ زٝؽٌ ي ؼأِش ضسٌغدٛء ٚي ؼىؽدسق زٚ.ٌَٛ ٌٝزٌٕفظ زٌّطّرٕع ٝ٘ أفعً أٛٔزع زٌٕفظ ٚ زأللشش زٌٟ ى ؼةسٌٝ. أِس عٓ عاللدع زٌدٕفظ ضسٌمغدذ فدسٌٕفظ ؼطةدس ٌٕٛعٙدس ٘دٝ زؽٌدؼ ٝدأِش إٔٙؼ ٚدٝ أؼ ٍٚدَٛ زٌمغذ عٍٝ فةً ِة١ٓ. ٚأِس عٓ عاللٙؽس ضدسٌشٚن فدسٌٕفظ زألِدسسظ ضسٌغدٛء ي ؼغدّٛ ضدسٌشٚن ضدً ؼةىدش صدفٛ٘سك أِدس زٌددٕفظ زٌٍٛزِدع ٚ زٌّطّرٕدع فّٙدس ٠غدّٛزْ ضددسٌشٚن ٚ ٠غسعذزْ عٍٝ صفسذٙس. ٚ أخ١شز ٚ ١ٌظ زخشز فمذ خٍك ى ؼةسٌٝ زٌشٚن ٚ زٌمغذ ٚ زٌدٕفظ فدؼ ٕٝدسغُ سزذدع ٚ زإلٔغدددسْ ٌدددٗ زٌخ١دددسس جِدددس أْ ٠ىغدددٓ زعدددؽغالٌُٙ ف١ٕدددسي سظدددس ى ؼةدددسٌٝ أٚ ٠غدددٝء زعؽخذزُِٙ ف١غعص ى ؼةسٌٝ عٕٗ. ______زٌىسؼطع: ع ط
100
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
وباء العصر : األمراض غٌر المعدٌة ______ام ىن تع إل فودان ىن يحب لى الب ط ن أ الولب؟؟ ام ىن تىن أن يوت ىببب ذا الى الذ ح ى ىىن يحب؟؟ ام ىن تعب تسلم بىعن ه آالم ىن يحب لان ا ن ع جز ا أى ى ؟ نحن نلقً الننب على األطباء والنظم الطبٌة وال ننظر إلى أصل المشكلة – فهى فً أنفسنا ونحن المتحكمٌن فٌها ...فلمانا ال نبدأ من اآلن؟؟ ______٠ّفً زإلسؼفسع زٌىسد زٌىسٌٟ ٌألِشزض غ١ش زٌّةذ٠ع ظشٚسظ ٍِىع فٟ عصشٔس زٌىسظش فٟ ل١ّدع أٔىسء زٌةسٌُ. ؼٚك١ش زٌط١سٔسغ زٌشصذ زٌصىٟ جٌٝ أْ ٕ٘سن أسضةع أِشزض غ١ش زٌّةذ٠ع شسذةع ٘دٝ أِددشزض زٌمٍددص ٚزألٚع١ددع زٌذ٠ِٛددع ٚزٌغددشغسْ ٚأِددشزض زٌمٙددسص زؽٌٕفغددٚ ِٟددشض زٌغددىشزٌطٌٟٛ ؽؼغطص فٟ 83٪ ِٓ زٌٛف١سغ ضسٌةسٌُ ع٠ٕٛس. ٚزٌىىّع زؽٌم١ٍذ٠ع، زؽؼ ٟؽٌصٛس أْ زألِشزض غ١ش زٌّةذ٠ع ٝ٘ ِكىٍع "زٌةسٌُ أٚي"، ٚ٘زز غ١ش صى١ه ضسٌّشظ جر أْ زٌط١سٔسغ زٌىس١ٌع: ي 30 ٛ١ٍِْ شخ زٌز٠ٓ ٛؼِْٛ ع٠ٕٛس ِٓ زألِشزض غ١ش زٌّةذ٠ع ٝ٘ أْ، ِٕٙ ٪61ُ ٠ة١كْٛ فٟ زٌطٍذزْ زٌّٕخفعع زٌذخً ٚزٌطٍذزْ زٛؽٌّعطع زٌذخً. ِٚٓ زٛؽٌّلع أْ ٠شؼفع ضٕغطع .0٪ عٍٝ ِذٜ زٌةمذ زٌّمطً، ِس ٌُ ؽ٠ُ زؼخسر خطٛزغ رزغ ِغضٜ عٍٝ زٌفٛس وّس ؼط١ٓ زألضىسؾ زٌة١ٍّع ٌٍطص زٌّغٕذ )ضسٌذ١ًٌ زٌةٍّٟ( أْ ٕ٘سن ص٠سدظ ِفشغع فٟ ِشض زٌطٛي زٌغىشٞ فٟ زٌّٕسغك زٌش٠ف١ع ِٓ زٌطٍذزْ زٌٕس١ِع ٚزٌطٍذزْ زٛؽٌّعطع زٌذخً. ضسعؽفٕسء أفش٠م١س لٕٛش زٌصىشزء زٌىطشٜ. ؽؼ ٚمسٚص زٌٛف١سغ ِٓ زألِشزض غ١ش زٌّةذ٠ع ز٢ْ ؼٍه زؼ ٟؽٌىذؾ ِٓ زألِشزض زٌّةذ٠ع ٚٚف١سغ زألِٙسغ ٚوذ٠فٟ زٌٛيدظ، ٚزؽٌغز٠ع. ٚرٌه أْ ِس ٠غّٝ ضأخطسء زٌىىّدع زؽٌم١ٍذ٠دع ٚ٘دٟ زيعؽمدسدزغ زٌخسغرع ضأْ زسؼفسع ِةذيغ زألِشزض غ١ش زٌّةذ٠ع ٘دٟ ضطغدسغع ١ؽٔمدع ـس٠ٛٔدع ٌكد١خٛخع زٌغدىسْ خطأ فسوش ١ٌٚظ ٌٗ أٜ عاللع ضدسٌٛزلع زألٌد١ُ و١دؿ أْ أوفدش ِدٓ 01٪ ِدٓ زٌةدصء زٌةدسؽٌ ٌٍّٟده زألِشزض دْٚ عٓ 1.. مَب أُ األٍشاض اىعقيٞة جَثو أمثش ٍِ ثي اىحنيفة. ٛ٘ٚ ألً ِٓ زٌٛزلدع . ٚزٌّف١ددش ٌٍمٍددك ٘ددٛ ِددس ٚسزء زٌّةسٔددسظ ِددٓ زٌّددشض ِٚةددذيغ زٌٛفددسظ زؽٌددؼ ّٟفٍٙددس ٘ددزٖ زألسلددسَ، فسألِشزض غ١ش زٌّةذ٠ع ؼثـش عٍطس عٍدٝ ز١ّٕؽٌدع، ألٙٔدس ؼدثدٞ جٌدٝ جسؼفدسع ؼىدس١ٌ زٌشعس٠دع زٌطط١دع ٚفمذزْ زإلؽٔسل١دع. ٚلدذ لدذسغ دسزعدع سعد١ّع أْ زؽٌىدس١ٌ زؽٌشزو١ّدع ِدٓ زألِدشزض غ١دش زٌّةذ٠دع ع١ىؼ5. ْٛشٛ١ٌْ دٚيس عٍٝ زأللً عسَ 8101 ِٓ خالي عدسَ ٚ .8131ٕ٘دسن ّٔدسرق زلؽصدسد٠ع أخددشٜ أعٍددٝ ضىف١ددش ِددٓ ٘ددزٖ زؽٌىددس١ٌ عٕددذِس ٠ثخددز فددٟ زإلعؽطددسس زإلعددؽٕضزف زٌددزؼ ٞغددططٗ ٘ددزٖ زألِشزض ٌّٛزسد زألفشزد ٚزألعش ٚعٕذِس ٠مذ زٌّصسضْٛ ضٙزٖ زألِشزض أٔفغُٙ غ١ش لسدس٠ٓ عٍٝ زٌةًّ، ِٛٚزلٙع زٌٕفمسغ زٌطط١ع زٌطس٘اع. ٚ فٟ زٌىم١مع ؼىّٓ زٌّأعسظ زألخالل١ع ٌٙزٖ زألِشزض أٔٗ ِّىٓ زٌٛلس٠ع ِٕٙس جٌٝ وذ وط١ش. ٚعٛزًِ زٌخطش زألعسع١ع زٌّغغططع ٌٙزٖ زألِشزض ِةشٚفع، ٠ّٚىٓ خفعٙس أٚ زٌمعسء عٙ١ٍس، جرز ِس ٛؼفشغ زإلسزدظ زٌغ١سع١ع ٚزيلؽّسع١ع ِٓ خالي ِىسفىع زؽٌطغ ٚزٌةذٚز١ٔع، ٚزٌىذ ِٓ ؾٍٛؼ زٌٛٙزء، 101
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
ٛؼٚف١ش زٌٛلطسغ زٌصى١ع ، ٚص٠سدظ زٌٕكسغ زٌطذٚ ، ٟٔخفط زعٙؽالن زٌىىٛي ِٚس ؽ٠سضةع ِٓ ِغىشزغ ؼغ١ص زٌز٘ٓ ؼٚذِشٖ. ٚ ،ٚ٘زٖ زٌةٛزًِ ِّىٓ أْ ؼمًٍ ضٕغطع 61٪ ِٓ أِشزض زٌمٍص، ٚزٌغىؽع زٌذِسغ١ع، ِٚشض زٌطٛي زٌغىشٚ ، ٞ 51٪ ِٓ أِشزض زٌغشغسْ. ٕٚ٘س ٌٕس ٚلفع ٌٕٕسشذ ٚٔطسٌص زٌىىِٛسغ زٌٛغ١ٕع، ٚزٌّمؽّع زٌذٌٟٚ ضسؽٌذخً زٌةٚ ٍّٟزٌةٍّٟ ٌٛل زٌٛضسء زٌضزو ٌألِشزض غ١ش زٌّةذ٠ع ٚ ؽ٠طٍص رٌه ِكسسوع "ل١ّع زٌةٕسصش زٌّثـشظ ضسٌّمؽّع" ضسعؽخذزَ ٙٔك عٚ ٍّٟفةسي. ٌٚزٌه فٕٙسن وسلع ٍِىع ؽٌغ١١ش ع١سعسغ ٚجلشزءزغ وى١ِٛع ٌٍغ١طشظ عٍٝ اى٘ببء اىدبزٌ ِٓ زألِشزض غ١ش زٌّةذ٠ع : فنٞف ٝنُ٘ رىل؟ ٠ّىٓ ٌٍىىِٛسغ أْ ؼةًّ عٍٝ ِغسعذظ زٌٕسط عٍٝ زٌىفسو عٍٝ صدىٙؽُ ظ ِدٓ خدالي عدٓ لدٛز١ٔٓ ؼمغ١ُ زٌّٕسغك ٚزعؽخذزَ زألسزظٟ زؼ ٟؽٌخٍك أِسوٓ صى١ع ٌغىسٙٔس ٌٍة١ش. ؽ٠ُٚ رٌه ِٓ خالي فشض ع١سعع "ِغ١ٕؽشظ" ٌٍكشوسغ زٌةس١ٌّع زٌىطشٜ ٌط١ع زٌغٍع غٛعس ٌٍصدىع. ٌٚىددٓ فددٟ زٌٛزلددع، ٌٚألعدد ٠طددشس زؽٌمددسس أفةددسٌُٙ ضمددٌُٙٛ، "أْ زألغةّددع ئزٌم١ددذظئ ٘ددٟ عددٍع عدد١رع ضٛٙزِش سضه ِٕخفعع ض١ّٕس زألغةّع ئزٌغ١رعئ ٟ٘ عٍع ل١ذظ ؼثدٞ جٌٝ سضى١ع." فسٌشضه ٛٔع١ٓ : سضه ِسدٞ – ٠ٕفك ضٗ عؼ ٍٝمسسٚ ٗؼسضه ِةٕدٞٛ ٠طدسسن ى ضدٗ فدٟ صدىٚ ٗؽِسٌدٗ ٚلذ ضذأ ٘دزز زٌفىدش زٌشزلدٟ زٌىدذؿ٠ ؽٕ٠كدش فدٟ زٌغدشش عٍدٝ أٔدٗ أدزٖ ٌٍشلدٚ ٟ زٌٛصدٛي جٌدٝ أعٍدٝ ِغ٠ٛؽسغ زٌىسلسغ ي "ِسعؽٌ (Maslow Hierarchy of needs) "ٍٛىم١دك زٌدززغ ضدأْ ٠ٕدسي زٌفدشد جو١ؽسلٗ ضسٌشظس عٕذِس ٠غةذ زٌغ١ش ٚضىً فةً ٠ٕفع ضٗ زٌغ١ش. ٠ٚةذ ِذخً زألخالل١سغ ٚزٌشٚوس١ٔسغ ِٓ زٌّذزخً زٌّّٙع ٚزٌّثـشظ فٟ ِٕع ٚعالق زٌىف١ش ِٓ ٘زٖ زألِدددشزض ٌٚألعددد فدددحْ زٌةٕددد زٌدددزٞ ٠ٕكدددش ِدددٓ خدددالي زإلعدددالَ ٚزٌغ١سعدددع ٚأ٠عددس زٌعدددغٛغ زإللؽصسد٠ع ٚزٌغ١سعد١ع ٚزإللؽّسع١دع زؽٌدٛؼ ٟزلٙٙدس زٌىىِٛدسغ ؼدٕةىظ عٍدٝ زألفدشزد فدٟ زٌةّدً ي ؼغسعذ عِٛ ٍٝزلٙع ؼٍه زألِشزض ضً ؽؼغطص فٟ جسؼفسعٙس. ______ٚلددذ لددسءغ زأل٠ددسغ زٌمش ١ٔددع ؽٌطدد١ٓ ٌٕددس أْ ؼٍدده زألِددشزض غ١ددش زٌّةذ٠ددع ِددس ٘ددٟ جي ؽٔددسق أعّسٌٕددس ٚشٛٙزؼٕس وّس فٟ لٛي ى ؼةسٌٝ فٟ زٌمشأْ زٌىش٠ُ: " مزىل ٝشٌٖٝ هللا أعَبىٌٖ زسشات عيٌٖٞ " )اىثقشة اٟٝة 761( "ٗئبحغ فَٞب آجبك هللا اىذاس اآخشة ٗال جْس ّصٞثل ٍِ اىذّٞب" )اىقصص األٝة 11( "ٗ مو ئّسبُ أىضٍْبٓ غبئشٓ فٜ عْقٔ" )اإلسشاء اٟٝة 71( "ٗئُ جصثٌٖ سٞئة بَب قذٍث أٝذٌٖٝ" )اىش٘سٙ اٟٝة 84( ٕٗررٚ خَٞعٖررب آٝرربت جسرر عيررٚ اىررحَنِ ٗاىسررٞطشة عيررٚ اىشررٖ٘ات ٗج٘خررٔ اىررْفس ببىعقو ئىٚ األصير. ______
102
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
أٍشاض اىقيب اىَنحسثة ______ٍشض سٍٗبجٞضً اىقيب . ٝعذ ٍشض سٍٗبجٞضً اىقيب ٍِ أمثش أٍشاض اىقيب اىَنحسثة شٞ٘عب فٜ اىعذٝذ ٍِ بيذاُ اىعبىٌ، ٗخبصة فٜ اىثيذاُ اىْبٍٞة. . ٕٚٗ زبىة ٍشظٞة جحسثب فٜ جيف ععية اىقيب ٗصَبٍبت اىقيب بسثب اىسَٚ اىشٍٗبجٞضٍٞة. . فسٌىّٝ زٌشِٚس١ؼض١ِع ؽٕؼك عٓ جصسضع زٌىٍك ضمشزـ١ُ زٌةمذ٠سغ ، ٚعسدظ ِس ٠طذأ ١ؽٔمع جٙؽٌسضسغ ضسٌٍٛص١ؼٓ فٟ زألغفسي زٌصغسس ِشغ ضذؼ ْٚكخ١ ِطىش أٚ عالق وسفٟ. . جْ زٌةصء زٌزٞ ٠غططٗ ٘زز زٌّشض عٍٝ زٌّمؽّةسغ )ِٓ زإلعسلع( ٔسلُ عٓ عذَ زإلوؽكسف ٚزٌةالق زؽٌّٕاُ ٌّشض زٌىّٝ زٌشِٚسؼض١ِع ٠ص١ص زألغفسي ٚزٌكطسش زٌز٠ٓ ٠ة١كْٛ فٟ زٌطٍذزْ زٌٕس١ِع ضغطص زٌفمش ٚعٛء زٌىسٌع زٌّة١ك١ع، ؽ٠ٚغطص فٚ ٟفسظ ِس ٠مشش سضع ٛ١ٍِْ وسٌع ع٠ٕٛس. . فٕٙسن ِس ي ٠مً عٓ 111ك811ك00 )خّظ عكش ٚ ْٛ١ٍِٔص ( ِٓ زٌٕسط ٠ةسْٛٔ ِٓ ٘زز زٌّشض ُِٕٙٚ عذد وط١ش ٠غؽذعٟ دخٛي زٌّغؽكفٚ ٌٝفؽشزغ ؽِىشسظ، ٚعذد خش ي ٠ّىٕٗ ؼىًّ ؼىس١ٌ زٌة١ٍّع زٌمشزو١ع فٟ زٌمٍص ؼٚىًّ زألعطسء زٌّسد٠ع ٌٍةالق ٚزؽٌّسضةع ٚزٌمشزوسغ زؽؽٌّس١ٌع ٌّعسعفسٙؼس. . جْ أعٛأ زٌّٕسغك ؼعشسز ٟ٘ ضالد أفش٠م١س ٚلٕٛش زٌصىشزء ٚلٕٛش ع١س ٚٚعٚ ػزٌّىػ١ زٌٙسدخ ٚزٌغىسْ زألص١١ٍٓ ألعؽشز١ٌس ٛ١ٔٚص٠ٍٕذز. . ٕٚ٘سن ٚزوذ فٟ زٌّسذع ِٓ ل١ّع أغفسي زٌّذزسط فٟ أفش٠م١س ٚ ع١س، ٚجل١ٍُ زٌكشق زٛؽٌّعٚ ،ػ أِش٠ىس زٌال١ٕ١ؼع ٠اٙش عٙ١ٍُ عالِسغ زٌّشض ٌٚىٓ ٕ٘سن 8 فٟ زٌّسذع أٚ أوفش ي ؼاٙش عٙ١ٍُ عالِسغ وس٘ش٠ع ٌٍّشض ؽ٠ُٚ جوؽكسفُٙ ضسٌّٛلسغ فٛق زٌص١ؼٛع عٍٝ زٌمٍص. . ٠ٚصً ِةذي زإلصسضع ضسٌّشض فٟ ِصش ِٓ 8 جٌٝ 08 فٟ زألٌ ؼٚمً فٟ زٌّذْ ؼٚض٠ذ فٟ زٌةكٛزذ١سغ ٚزٌش٠ جر جٙٔس ِشؼططع جسؼطسغ ٚـ١ك ضسٌفمش ِٚغٜٛؽ زٌّة١كع ٚزٌضوسَ ٚلٍع ز٠ٛٙؽٌع ٚلٍع زؽٌةشض ٌألشةع زٌطٕفغم١ع ٌعٛء زٌكّظ. . ٠ّٚىٓ زٌٛلس٠ع زأل١ٌٚع ِٓ زٌىّٝ زٌشِٚس١ؼض١ِع زٌىسدظ )ِٕع زإلصسضع زأل١ٌٚع( ضسٌةالق زٌّطىش ٚزٌىسًِ يٙؽٌسضسغ زٌىٍك زٌىسدظ )زٌٍٛص١ؼٓ( زٌٕسلّع عٓ زٌّمّٛعع )أ( ٌٍطى١ؽش٠س زٌةمذ٠ع ٚرٌه ِٓ خالي ؼٕسٚي زٌطٕغ١ٍٓ ١ِٛ٠س ٌّذظ ي ؼمً عٓ 01 أ٠سَ عٓ غش٠ك زٌفُ أٚ ومٕع ٚزوذظ ٌٍطٕغ١ٍٓ غ٠ًٛ زٌّفةٛي ضسٌةعً ِع ؽِسضةع زٌطفً ضسٌفى زٌذٚسٞ عٍٝ زٌمٍص. )ٚي دزعٟ إللشزء ع١ٍّع لشزو١ع إلصؽرصسي زٌٍٛص١ؼٓ جي فٟ وسيغ ٠مشس٘س زٌطط١ص زٌّةسٌك(. © االجسبد اىعبىَٜ ىيقيب (WHF)ٗ ٍشمض صسة اىقيب )HEARTS-AFCRHD) .http://www.afrhd.com/article
103
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
التدخٌن عامل خطر ألمراض القلب واألوعٌة الدموٌة ... ٌمكن تفادٌها تماما! ______
التبغ وأٍشاض اىقيب ٗاىششاِٞٝ
إن الترردخين يبرربب 25 فرر الى ئررة ىررن أىرر ا الولررب األ عيررة الدى يررة، رر البرربب ال ئيب الث ن ألمراض القلب والشراٌٌن ، بعد ا تف ضرط الدم.
ال يوتص تسثي دخ ن التبغ عل الىدخنين فوط ب إن التدخين البلب الذ يتع ل األطف يببب لهم إلته ب ىتا ة ىزىنة ف ال ئة األذن ال بط الجي ب األنفيرة حب بية الجلرد الجهر ز العصرب ىىر يراث علر إضرط اب فر التحصري الد ابر الت ايز البل ، لد االً األطف الذين يتع ض ن للتدخين البلب .
نرر ، ىرر يورر ب ىررن 6 ىليرر ن شررخ يى ترر ن ىررن تعرر ط التبررغ أ التعرر للرردخ ن البلب ، ى يىث 6 ف الى ئرة ىرن اإلنر ث 22 فر الى ئرة ىرن فير الرذا فر جىيو أنح ً الع لم بن ي .
بحلرر عرر م 2535 ىررن الىت قررو أن تصرر ال فيرر الى تبطررة ب لترردخين إلرر 8 ىليرر ن ح لة ف ة بن ي ىو ذل، فإن آث التدخين يىان تجنبه بر لنه بعر لم خر ىرن التبرغ لررذل، فهرر أ ل يررة ئيبررية البررت اتيجية االتحرر د العرر لى للولررب الىنظىرر الع لىيررة األخ . كٌ ٌسبب التبغ أمراض القلب والشراٌٌن ؽ٠غطص زؽٌطغ فٟ أِشزض زٌمٍص ٚزألٚع١ع زٌذ٠ِٛع ضطشق ِخؽٍفع ، عدٛزء عدٓ غش٠دك زؽٌدذخ١ٓ أٚ زٌّعغ ، فٛٙ ٠صً جٌٝ زٌذَ ف١غدطص أظدشزس وحسؼفدسع ِثلدػ فدٟ ظدغػ زٌدذَ ٠ٚمٍدً ِدٓ زٌمدذسظ عٍٝ ِّسسعع زٌش٠سظع. ٚ عددالٚظ عٍددٝ رٌدده فددحْ زؽٌطددغ ٠مٍددً ِددٓ و١ّددع زألٚوغددم١ٓ زؽٌددٟ ٠ىٍّٙددس زٌددذَ جٌددٝ ألٙددضظ زٌمغددُ زٌى٠ٛ١ع ِفً زٌذِسغ ٚزٌىطدذ ٚزٌمٍدص ٠ٚض٠دذ ِدٓ زؽٌةدشض ٌدؽمػٍ زٌدذَ، فىدذؾٚ لٍطدسغ زٌدذَ فدٟ زٌكشز١٠ٓ ٠غطص ِمّٛعع ِٓ أِشزض زٌمٍص زؼ ٟؽٌثدٞ فٙٔ ٟس٠ع زٌّطدسف جٌدٝ زٌّدٛغ زٌّفدسلد أٚ زٌغىؽع زٌذِسغ١ع. زقبئق ببألسقبً! • زؽٌذخ١ٓ ؽ٠غطص فٚ ٟزوذ عٍٝ عكشظ ِٓ أِشزض زٌمٍص ٚزألٚع١ع زٌذ٠ِٛدع فدٟ ل١ّدع أٔىسء زٌةسٌُ وّس ؽ٠غطص فٟ وذؾٚ ٔىٛ 8 ِال١٠ٓ وسٌع ٚفسظ ع٠ٕٛس. • خطش زإلصسضع ضأِشزض زٌمٍص زؽٌسل١دع ٘دٟ 80 % أعٍدٝ فدٟ زإلٔدسؾ زٌّدذخ١ٕٓ عٕٙدس فٟ زٌزوٛس ِٓ زٌّذخ١ٕٓ.
104
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
• خطددش وددذؾٚ زٌٕٛضددسغ زٌمٍط١ددع فددٟ زٌّددذخٓ ٠ض٠ددذ ضٕغددطع 0.8 % ٌىددً عدد١مسسظ ١ِٛ٠ددس. • ِعغ زؽٌطغ ٠عسع خطش زإلصسضع ضسٌٕٛضسغ زٌمٍط١ع. • زٌٛعٝ ضؽأـ١ش زؽٌذخ١ٓ عٍٝ وذؾٚ أِشزض زٌمٍص ٚزألٚع١ع زٌذ٠ِٛع ي ؼضزي ِٕخفعع ٌددذٜ وف١ددش ِددٓ زٌّمؽّةددسغ: ففددٟ زٌصدد١ٓ، و١ددؿ ٠ةددذ خطددش وددذؾٚ وددسيغ زٌغددىؽسغ زٌذِسغ١ددع ؽؼضز٠ددذ ضٕغددص عس١ٌددع لددذز، فددحْ أوفددش ِددٓ 1. % ِددٓ ل١ّددع زٌّددذخ١ٕٓ ي ٠ةشفْٛ أْ زؽٌذخ١ٓ ٠ض٠ذ ِٓ ِخسغش زإلصسضع ضغىؽع دِسغ١ع. • عٍّس ضأْ جلشزءزغ زٌىاش ِٓ زؽٌذخ١ٓ ؼثدٞ جٌٝ خفط ِةذيغ زإلصدسضع ضسألصِدسغ زٌمٍط١دع، وّدس ؼكد١ش زألدٌدع زٌة١ٍّدع جٌدٝ أْ فدشض زٌمدٛز١ٔٓ ٚزٌةمٛضدسغ ٌىادش زؽٌددذخ١ٓ وسٛؽٌعددع فددٟ زألِددسوٓ زٌخس١ٌددع ِددٓ زؽٌددذخ١ٓ ؼةددذ ِددٓ أوفددش زٌطددشق غ١ددش زٌّىٍفددع ٌّٕددع زٌٕٛضسغ زٌمٍط١ع.
اىحعشض ىيذخبُ اىسيثٜ ٗعالقحٔ بأٍشاض اىقيب ٗاىششاِٞٝ o ٕ٘سن ِخسغش ؽٌٍةشض ؽٌٍذخ١ٓ زٌغٍطٟ ِّسـٍدع أٚ لدذ ؼىدْٛ أوفدش ِدٓ زؽٌدذخ١ٓ رزؼدٗ ، فغ١ش زٌّذخ١ٕٓ زٌز٠ٓ ٠غؽٕكمْٛ زٌذخسْ زٌغٍطٟ ٠ضدزد ٔغطع خطدش ؼةشظدُٙ ألِدشزض زٌمٍص ٚزٌكشز١٠ٓ ض١ٓ 80 ج31ٌٝ %. o زؽٌةددشض ؽٌٍدددذخ١ٓ زٌغدددٍطٟ ٠مؽدددً 111ك811 شدددخ ودددً عدددسَ ، 86 % ِدددُٕٙ ِدددٓ زألغفسي ٚزٌطسٌغ١ٓ ، ٠ٚىْٛ أوفش ِٓ 61% ِٓ ٘زٖ زٌٛف١سغ ٔسؼمع ِٓ أِشزض زٌمٍص ٚزٌكشز١٠ٓ. o فددٟ ِةاددُ زٌددذٚي زؽٌددٟ شددٍّٙس زيعددؽطالع وددٛي زٌةددسٌُ، فددحْ زٌغسٌط١ددع ِددٓ زٌّددذخ١ٕٓ ٠شغطْٛ فٟ زإللالع عٓ زؽٌذخ١ٓ. ٚ oفٟ عسَ 8118 ضسٌص١ٓ، ٚلذ ضسٌطىؾٛ أْ زؽٌةشض ؽٌٍذخ١ٓ زٌغٍطٟ ٠مؽً عذد وط١دش ِٓ زٌٕغسء ِفً زؽٌذخ١ٓ فٟ وذ رزؼٗ. ٚ oلددذ ٚلددذ أْ زؽٌةددشض زؽٌّىددشس ٌددذخسْ زؽٌطددغ، عددٛزء فددٟ ِىددسْ زٌةّددً أٚ زٌّٕددضي، ٠عسع خطش زيصسضع ضٕٛضع لٍط١ع. o زؽٌةشض ؽٌٍذخ١ٓ زٌغٍطٟ ٠غطص ِس ٠مذس ضٕىٛ 111ك813 وسٌدع ٚفدسظ عد٠ٕٛس ضد١ٓ غ١دش زٌّذخ١ٕٓ، ضّس فٟ رٌه 111ك3.8 وسٌع ٚفسظ ضغطص أِشزض زٌمٍص زإللفسس٠ع فٟ ل١ّع أٔىسء زٌةسٌُ.
جأثٞش اإلقالع عِ اىحذخِٞ فٟ غعْٛ 81 دل١مع ِٓ زإللالع عٓ زؽٌذخ١ٓ، ٠ةدٛد ظدغػ زٌدذَ ٚزٌٕدطط جٌدٝ ٚظةّٙس زٌطط١ةؽؼٚ ،ٟىغٓ زٌذٚسظ زٌذ٠ِٛع. ٚ فددٟ غعددْٛ 6 عددسعسغ، ؼةددٛد ِغدد٠ٛؽسغ زيٚوغددم١ٓ فددٟ زٌددذَ ؼٚطددذأ فددشص وذٛٔ ؾٚضع لٍط١ع فٟ زئخفسض. ٚ فددٟ غعددْٛ 85 عددسعع، ٠ددؽُ زٌددؽخٍ ِددٓ أٚي أوغدد١ذ زٌىشضددْٛ ِددٓ زٌمغددُ ٚزٌشذ١ؽٓ ضطشد زٌّخسغ ٚزٌىطسَ.
105
MCFC -Egyptian Journal of Breastfeeding (EJB) Volume (7) Jan- May, 2013
ٚ فددٟ غعددْٛ 8. عددسعع، ؼددؽّىٓ زٌددشذ١ؽٓ ِددٓ أخددز سصدد١ذ ِددٓ زٌٙددٛزء ضؽىغددٓ زؽٌٕفظ وؽؼ ؿ١فؽه زٌمٕٛزغ زٌٛٙزذ١ع ٚزألٔغمع زٌشذ٠ٛع. فدٟ غعددْٛ خّددظ عدٕٛزغ، ٠ددٕخفط خطددش وددذؾٚ زٌٕٛضدع زٌمٍط١ددع جٌددٝ ٔىددٛ ٔص ٘زز زٌةذد ضسٌّمسسٔع ٌٍّذخ١ٕٓ. فٟ غعْٛ 01 عدٕٛزغ، ٠دٕخفط خطدش زإلصدسضع ضغدشغسْ زٌشذدع جٌدٝ ٔىدٛ ٔص ٘زز زٌةذد ضسٌّمسسٔع ٌٍّذخ١ٕٓ. فٟ غعْٛ 00 عٕٛزغ، ؼمً خطش زإلصسضع ضأِشزض زٌمٍص ٚزٌكدشز١٠ٓ ؽٌصدطه ِمسسضع ٌٍز٠ٓ ٌُ ٠ذخٕٛز أضذز . زإللددالع عددٓ زؽٌددذخ١ٓ أدٜ جٌددٝ ص٠ددسدظ فددٟ عدد١ٕٓ زٌةّددش زٌصددى١ع )ضددذْٚ جعسلددع( وؿ١ زوؽغص زٌشلسي ع١ؽٕٓ ِٓ زٌةّش، ٚزٌٕغسء وذ ٠صً جٌٝ ..3 عٕٛزغ
© االجسبد اىعبىَٜ ىيقيب (WHF)ٗ ٍشمض صسة اىقيب )HEARTS-AFCRHD) http://www.afrhd.com/article
106