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breast feeding
Breast feeding has been the most natural response of a mother to satisfy the emotional and nutritional needs of her infant. That this can even serve as a natural barrier to infections and even save us money is perhaps not thought of. The effectiveness of the breast milk has long been established for reducing diarrhea, pneumonia, improved child nutrition and development along with its potential as Eco-friendly.
Breastfeeding benefits all sectors of society economically, ecologically and socially. However, over the last decades, women's self confidence in their capacity to nourish their infants has been undermined by many factors, including the power of the infant formula industry and a lack of social support. The major reasons for decline in breast feeding practices in India (50.9% by 3 months) are 1.rapid urbanization. 2. commercial pressure by marketing companies giving false messages. 3. lack of self confidence in mothers & dislike for breast feeding with the fair of loosing charm and beauty. 4. Practical problems of working mothers. 5.Most important improper technique and positioning while breast feeding leading to cracked nipples, engorgement of breasts and thus lactational failure a common problem faced by young mothers.
6. Delayed initiation of first feed leading to failure of lactation reflex.
7. Starting bottle or pacifiers along with breast feeding thus confusing the baby while sucking.
These and many other factors lead to failure to initiate breast feeding and an excuse for the mother to say I don’t have enough milk which is absolutely a myth because nature has been kind enough to provide milk to all the mammals to feed their young ones even to multiple ones at a time.
Benefits of breast feeding:-
There are many positive reasons for women to breastfeed their babies: breast milk is the best and most nutritious food, protecting them from illness and ensuring healthy physical and psychological development. For mothers, breastfeeding provides several health benefits such as reduction in the risk of breast and ovarian cancer, with the decrease in breastfeeding over the past several years one could daily hear the bad news of breast cancer in very young ladies attributed to hormonal imbalance led by stopping breast feeding their babies, a protective mechanism provided by nature. Breast feeding also helps in diminishing post-partum bleeding and iron deficiency anemia, and a natural means of spacing children by delaying ovulation. Breastfeeding also empowers women by increasing their self-confidence in their capacity to nourish and protect as well as nurture their babies and by decreasing their dependence on commercial products.
Millions of babies fall ill every year because they are not breastfed. The World Health Organization (WHO) estimates that more than 1.5 million infant deaths could be avoided every year if all babies were breastfed. It has been observed that infants under 2 months of age are nearly six times more likely to die if not breastfed.
A study from Ghana on 10947 breastfed babies concluded that we could save 22 %( 2.5 lakh) neonates from death if breastfeeding was initiated within one hour of birth.
In Botswana in 2005/06, infant formula feeding was given to all the babies with the aim to prevent transmission of HIV infection fro their mothers suffering from AIDS. This led to increase in diarrheal disease in these children with the increase in national under five mortality by 18%.also hospital admissions increased by 50%. Breast milk being free of contamination, adulteration and available at desired temperature has been proven best anti-infective. This property is being attributed to certain immunoglobins, compliments, macrophages, lysozymes present in breast milk particularly during first few days (colostrum).

Incidence of atherosclerosis and various related heart ailments are on lower side in people, those who are exclusively breast fed in childhood .breast fed babies have also proven highly intelligent than artificially fed babies .

Artificially fed babies have to bear extra financial burden for purchasing milk, bottle, fuel etc., which amounts to almost Rs 1500-2000/month, which is beyond the capacity of average middle class family, which compels them to over dilute the milk, thus leading to malnutrition. at the national level almost Rs 15000-20000 crores (estimated cost of marketed milk)can be saved by breast feeding approximately 22 million babies born per year.
Perhaps the least known of all the advantages of breastfeeding are the ecological benefits. Breast milk is a natural and renewable resource which is often overlooked. Breastfeeding protects the environment by reducing the demands made on it and eliminates sources of waste and pollution. Artificial baby milks and processed baby foods are non-renewable products which create ecological damage at every stage of their production, distribution and use.
Breastfeeding is unique - it causes no pollution and is the best example of how humanity can sustain itself through provision of the first and most complete food for human life. It is vital to increase our efforts to support, protect and promote breastfeeding. All sectors of society need to learn about the advantages of breastfeeding and how to support the natural rights of mothers to breastfeed and babies to be breastfed. All women should have access to information and support in order to be able to make truly informed choices about these natural rights.
The breastfeeding culture is culture of peace, balance and harmony. It involves trusteeship and global responsibility towards our young, and seeks accountability from governments and various spiritual traditions to support families in nurturing children. Almost all great world religions recognize breastfeeding as a essential nurturing the young and respect women's role in doing so.
Processing artificial baby milks wastes energy
Baby milk consists of a mixture of factory-processed substances which may be then added to cow's milk and converted into powder at high temperatures. This wastes a lot of electrical energy. This energy usually comes from hydro-electric or nuclear power plants that are expensive and cause a lot of damage to the environment. Breast milk is naturally produced. A mother's normal low-cost diet is transformed into a natural, invaluable and specialized food for her baby! This is the most energy efficient food production system ever known!
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Breast milk needs no extra-packaging
The packaging of manufactured baby milk wastes tin plate, paper and plastic. Bottles, teats and other feeding equipment use plastic, rubber, silicon and glass. To bottle feed all US babies, the 550 million tins sold each year, stacked end to end would circle the earth one and a half times. In 1987, 4.5 million feeding bottles were sold in Pakistan alone. These feeding bottles stacked end to end would reach the top of Mount Everest.
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Disposal methods pollute air, land and groundwater
The packages used for baby foods, along with feeding bottles, teats and pacifiers, are commonly thrown away after use. Normally these are not biodegradable. Plastic feeding bottles, teats and pacifiers take 200 to 450 years to break down when disposed in landfills. Glass feeding bottles take an undetermined amount of time to break down. Landfill and incineration are the most common disposal methods. Landfill sites can pollute groundwater, and there is a shortage of suitable sites in some countries. Incineration releases pollutants into the air: if plastic bottles are burned, the fumes may contain dioxin and other toxic substances. The beauty of breast milk is that one need not worry about disposal and it is immediately available without any need for packaging and preparation. Breastfeeding is waste free.
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Transportation pollutes and wastes fuel
The fresh cows' milk, grains and additives used in making baby food travel long distances even before processing, and additional long distances on the way to central, then regional warehouses, and finally, retail outlets. Many countries import baby food and feeding bottles from the other side of the world. This means a great waste of fuel and contributes to air pollution everywhere. Breast milk does not have to be shipped around the world; every mother has a ready supply wherever she goes...
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Preparation - more waste
A 3 month old bottle-fed baby needs a liter of water per day to mix with the formula powder. Another two liters are needed to sterilize the bottles and teats. If the water is boiled over a wood fire, more than 73 kg of wood are needed to prepare a year's feeds. In many parts of the world, water and fuel are so scarce that few mothers have the luxury of keeping the bottles and teats clean and of using only boiled, cooled water to make up the feeds. Breast milk is ready to use at the right temperature, does not need to be sterilized and causes no pollution.
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Processed baby milks maybe contaminated
Baby milk is an industrially manufactured food which undergoes multiple processing, additions and alterations as it is converted from cows' milk plus additives to a can full of powder. No wonder that it has proved vulnerable from danger to contamination by harmful bacteria like E. Sakazakii and Salmonella, radio-activity, chemicals, foreign bodies and insect pests. Furthermore, the water mixed with the powder poses another danger of contamination, while problems have also arisen from teats breaking during use. Breast milk is a living substance. Each woman's milk is individually tailored for her own baby. What's more, her milk changes constantly - both during a feed and day by day - to meet her baby's evolving needs. When a mother is exposed to pathogens in the environment, she produces antibodies to combat them. The mother's antibodies are then passed on to her baby via her breast milk.
The dangers of Donations
Many violations of the code have been observed in emergencies with the donations of breast milk substitutes. During earthquake in Indonesia 2006, distribution of donated formula to children under 2 years led to increased prevalence of diarrheal disease to 25%, compared to 12% in breastfed babies.
Similarly in 2005 tsunami in Pondicherry, the occurrence of diarrhea was three times more among children who were fed with free breast milk substitutes than in those who were not fed with the same. These figures clearly show the misuse of these donations.

IMS Act and breast feeding:
To encourage and promote breast feeding various organizations like BPNI,IBFAN etc have been playing a commendable job by providing training people including health personnel ,highlighting benefits and objectives of breast feeding through printed and electronic media and interacting with various government officials for strict implementation of IMS (infant milk substitution act)1992 and amended in 2003 through the act of parliament and as per this act it is illegal:
1. To promote infant milk substitutes and feeding bottles intentionally /unintentionally on pretext of distribution of educational material
2. To make advertisement or exhibition of these products.
3. To sponsor any health official or related to child welfare to any tour, conferences etc.
4. To provide gifts or monitory benefit.
5. To distribute literature which directly or indirectly helps in promotion of their products and thus undermining breastfeeding?
DR.NIYAZ AHMAD BUCH
PROFESSOR (pediatrics).
SKIMS MEDICAL COLLEGE
SRINAGAR.
National trainer for infant and young child feeding
Niyaz_buch@yahoo.co.in

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overview of infant feeding and AIDS
Topic: - “Overview of AIDS in Children”

Author:-
Dr. Niyaz Ahmad Buchh.
Associate Professor (Pediatrics)
SKIMS Medical College,
Bemina, Srinagar.

Address for correspondence:-
Dr. Niyaz Ahmad Buchh,
Children’s Clinic Rainawari,
Srinagar Kashmir 190003.
Mobile:-9419478800
Pg 1/4
A).Defining HIV & AIDS:-
HIV: - Humane immunodeficiency virus is a virus that destroys part of the body’s immune system.
AIDS:-Acquired immunodeficiency syndrome is the final stage of the disease caused by HIV.
B).Epidemiology of AIDS:-
1. First case of childhood AIDS was detected in an infant in 1983.
Seropositivity of HIV in blood was noticed in 0.1-1.5% babies (ICMR Report 1988).Whereas same was noted in 8.9-9.3% multitranfused babies of thalasemia, hemophilia etc in a Delhi study 1993.
2. WHO had estimated > 42 cases of AIDS including 4 million in India by 2002.
3. 2.7 million Children are < 15 years of age.
4. 5 million new cases are to be added annually including 0.8 million children.
5. 3 million die including 58,000 children.
6. 10 million children are orphaned and estimated 20 million by 2010.
7. >90% live in developing nations and sub-Saharan areas.
It is worth to highlight pediatric AIDS because it has got unique mode of transmission, diagnostic difficulties, nonspecific clinical features and of course having high mortality because of its rapid progression and most of them die within 1st two years of life due to high viral load and depletion of infected CD4 lymphocytes in infants than adults. I n childhood AIDS usually mother is the source (symptomatic or asymptomatic) and father the cause and the child suffers due to none of his own fault. The disease seems to be disease of whole family.
C).Transmission of AIDS in Children:-
1. Vertical Transmission: Almost 90-100% children <13 years in USA and 74-86% in India acquire AIDS through vertical transmission from their mothers, also called as parent-to-child transmission (PTCT). The infection is transmitted during,
a) Antenatal period during pregnancy through placental circulation (30-40%).Virus has been detected as early as 10 weeks gestation in an aborted fetus by culture and polymerase chain reaction (PCR) within 48 hours.
b) Intrapartum period during delivery through contaminated secretions and blood in birth passage (60-70%).It is detected by culture and PCR within 4-6 weeks.
c) Postnatal period through breast feeding and have increased chances of transmission from HIV +ve mothers by 14%.It is detected by 3-6 months by culture and PCR.Chances of transmission through breast milk are high because early breast milk is moiré cellular, lacks specific HIV Ig A antibodies and rate of transmission is reduced by half on stopping breast milk.
2. Transfusion of blood products in 3-6% cases, which was more common earlier before routine screening of blood and its products was done.
3. Others like syringes and needles etc which is very rare in children.
4. Sexual Abuse:-Very rare in children, however, fast growing cause of transmission in USA in adolescent group (13-19 years).
D).Factors influencing PTCT transmission of AIDS in children:-
1. Recent infection of HIV infection.
2. Severity of HIV infection.
3. Infection with other sexually transmitted disease.
4. Obstretic procedures like vacuum extraction or forcef delivery leading to injury to body.
5. Duration of breast feeding increases risk of transmission by 14-29% if given for first 5 months of life.
6. Exclusive breast feeding or mixed feeding, since chances of intestinal epithelial damage more in mixed feeding, thus transmission of HIV infection more in mixed feeding.
7. Condition of breasts like cracked nipples, breast abscess etc.
8. Condition of baby’s mouth like abrasions, ulcers etc.

Pg 2/4
9. Provision of antiretroviral drugs.
10. Advanced maternal age increases chances of transmission.
11. Low CD4 count in mother as well as in baby.
12. High maternal viral load. If mother has <50,000 copies /ml (1.6% fold risk) compared to if >50,000 copies/ml (3.7% fold risk).
13. No antiretroviral therapy given during pregnancy, delivery and breast feeding.
14. Low antiviral antibodies in mother.
15. Preterm and low birth weight babies have 3.7 fold increased risk, if born <34 weeks of pregnancy.
16.1st born of the twin babies has 2 fold increased transmission due to more trauma and exposure to contaminated secretions in birth passage.
17. Use of illicit drugs y mother during pregnancy.
18. Delivery by Caesarian section decreases transmission by 87%, if done along with Zidovudine therapy in both mother and baby as well.
E).Feeding of baby of HIV positive mother:-
It has been observed in a study from developing country that out of 25 babies, relative risk of death due to diarrhea increases if baby is given formula feeds during 1st year of life comparing to one who is exclusively breast feed. The risk increases to 23/25,if given formula feeds during 1st 2 months of life comparing to 1/25,if exclusively breast feed. Same is increased chances of deaths due to respiratory infections in formula feed babis.Because of these complications a policy statement on HIV and infant feeding has been developed collaboratively by UNAIDS,WHO & UNICEF(1997).which says,
“AS a general principle, in all populations, irrespective of HIV infection
rates, breast feeding should continue to be protected, promoted and
supported.”
This principle holds good particularly in developing countries like India where breast feeding as recommended by WHO, should continue despite mother being HIV+ve and chances of transmission being more in breast fed babies but simultaneously the mortality and morbidity being much higher in artificially fed babies in our social set up.
F).AFASS Criteria for replacement feeding for baby of HIV positive mother:-
a) Acceptability: - Will not breast feeding stigmatize and discriminate family/mother?
b).Feasibility:- Does mother/family have adequate time skills, resources and support for correct preparations and feeding.
c).Affordability:-Can family afford purchase, preparation, storage and associated cost of preparation and feeding?
d).Sustainability:-Is continuous uninterrupted and dependable system of distribution of all products for duration of replacement feed available?
e).Safety:-Would replacement feeds be correctly and hygienically stored and prepared and fed in clean cups and pots with clean hands?
G).Breast milk feeding options by HIV+ve mothers:-
1. Exclusive breast feeding for 6 months and continued breast feeding fat least for 2 years.
2. Modified breast feeding by exclusive breast feeding for shorter duration followed by early replacement feeding by home made commercial formulas.
3. Expressed breast milk and heating it by flash method for a longer period before feeding.
4. Breast feeding by HIV-ve mother (donor’s breast milk).
All these options are discussed with the mother and if possible with the family and proper feeding advised keeping in mind various social and economic factors of the family.


Pg 3/4
H).Clinical features of childhood AIDS:-
Clinical features are nonspecific and vary from infants to older children, the latter behaving like adults. Infant may be normal at birth, or with lymphadnopathy, hepatosplenomegaly, rash, fever, recurrent diarrhea, oral thrush and chronic parotid swelling etc.
In older children almost all systems are involved, leading to progressive encephalopathy, Pneumonia, cardiomyopathy, malabsorption syndrome, renal involvement, dermatitis, anemia, Lymphoma and various opportunistic infections like tuberclosis, canadidiasis etc.
I).Diagnosis of AIDS:-
a) Clinical features but unfortunately these are nonspecific.
b) Screening of mother.
c) Immunological tests.
1. ELISA:-commonly practiced but less specific. Two successive ELISA with different proteins if +ve is suggestive of AIDS.
2. Western Blot Test:-detects antibodies to various structural proteins of virus like
Envelope:-gP160, 120, 41,
Gag:-P 55,40,24,17,
Pole:-P66, 51, 32.
WHO criteria is 2 out of 3 proteins if +ve is diagnostic, but the test is expensive and nonavailble everywhere.
3. Culture and PCR: - more helpful in perinatal AIDS and 100 % specific if done together in perinatal AIDS.
J).Prevention of childhood AIDS:-
1. Decrease maternal viral load by antiviral therapy.
a). Thai Trial advocates 300 mg of AZT from 36 weeks of pregnancy followed by 300 mg during delivery and stop breast feeding, has decreased transmission by 50%.
b). Ultra short Regimen in Uganda adopts single dose of oral Nevirapin 200 mg to mother at labour and 2 mg/kg to new born within 72 hrs of birth and relative risk is decreased by 42%. 100 countries have started this regimen.
2. Decrease exposure of fetus during delivery by performing elective Caesarian section.
3. Safer infant feeding practices as discussed above.
4. Primary prevention of AIDS by parents by avoiding extramarital sex, performing safe sex, safe syringe precautions and tested blood transfusions etc.
K).Summery of Childhood AIDS:-
a).AIDS is emerging as rapidly one of the major public health problems in India.
b).Approximately 30,000 newborn babies in India suffer due to PTCT.
c).Prevention of PTCT important strategies to decrease pediatric HIV infection.
d).Single dose Nevirapin to mother and baby at labour and within 723 hrs of birth effectively decrease vertical transmission.
e).Diagnosis of HIV very crucial with excellent laboratory back up.
f). Most rapid progression and fulminant course in infants and children.
g).Above all breast feeding to continue even by HIV+ve mothers in developing countries, however other feeding options to be adopted on individual basis.
Pg 4/4

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