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Breastfeeding problems and food supplements. Any association?

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Casie Tesfai

Normal user

16 Feb 2011, 16:07

Why is it in the SFP we find the following as admission criteria:

'Lactating women with an infant < 6 months if they have breastfeeding problems or if the infant is not gaining weight adequately.'

Let me just clarify. I completely acknowledge that lactating women need further nutritional support especially if they are of poor nutritional status, but what I'm not quite sure about is the association between breastfeeding problems and supplementary feeding. I'm of the understanding that there is not one. It seems that the assumption according to the above criteria is that all breastfeeding problems are due to a physiological lack of milk which the food supplement will improve?

Research has shown (Prentice et al, Eur J Clin Nutr, 1994; 48: S78-89) that lactational performance has not been shown to be associated with BMI, even at a BMI of <18.5 kg/m2 or < 16 kg/m2 a woman's lactational performance seems to be unaffected. So it appears then that eating a 'better' diet will not increase milk output.

Many women irrespective of nutritional status have breastfeeding problems and complain of not having enough milk, especially in the countries where I've worked. There is also extensive research (Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007) that shows that appropriate breastfeeding support improves 'breastfeeding problems.' Further, when an infant (<6 mos) is severely wasted, we recommend a special supplemental suckling technique with therapeutic milk with the aim of re-establishing breast milk and correcting the breastfeeding problem.

It seems to me that the majority of breastfeeding problems (not including the very small % that may have a physiological problem or emergency situations) are associated with poor practices. Unfortunately, I also find that many health/nutrition workers even doctors are unfamiliar with how to assist a woman and correct the breastfeeding problem; rather I observe many of them are quick to lecture her on eating a 'better' diet. (We're currently assessing this in the country where I work).

From a survey I conducted in another country, approximately 70% of mothers of wasted children reported they did not exclusively breastfeed because at one point they felt they did not have enough milk. I am not concluding that this was the cause of wasting, but it made me realize it was a bigger problem than I had initially understood. Further qualitative assessments showed that one of the most common reasons women felt they did not have enough milk were due to not eating a 'good' diet. When asked where they learned this, they reported from the health and nutrition workers.

Coming back to my question, I am of the opinion that by responding with supplementary feeding to a woman with a breastfeeding problem, we are further contributing to spreading erroneous beliefs while doing nothing to improve the 'real' problem.

So why is that criteria part of the SFP? And can anyone share more research with me in this particular area?

Many thanks

Marie McGrath

ENN

Forum moderator

16 Feb 2011, 20:54

Dear Casie
Many thanks for flagging this issue. I want to share with you the report of the Management of Acute Malnutrition in Infants (MAMI) Project, that ENN undertook in a collaboration with the Centre for International Health and Development (CIHD) London in 2008/09 to investigate managament of acute malnutrition in this age group. See the full report at:http://www.ennonline.net/research/mami

The researchers also found what you describe here. I think the 'bottom line' is that programmes like SFPs and TFCs are designed for infants over 6 months of age. At worst, there is a 'blind spot' to malnutrition in this age group and infants <6m are not admitted/referred on. At 'best', they are admitted as you describe, but at risk of reinforcing the notion that breastmilk is inadequate and/or the mother's diet is limiting breastmilk production in some way. So programmes - which often may lack the skillset to truely manage infants <6m, eg through skilled breastfeeding counselling - must rely on what they have to hand - food rations for mothers.

The MAMI Project report is large but a good read if you want to delve more into this area (I am biased, I know!) - it concludes with some strong observations about the lack of evidence base to manage this age group and the need for considerable research on this topic. In the interim, the skilled infant feeding counselling support of programmes needs to be strengthened.

You will also see at the link above, a recent publication in the Archives of Disease in Childhood, based on some of the MAMI report findings. "Kerac et al, 2011. Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards:a secondary data analysis. This highlights the importance of addressing the situation you describe.

André BRIEND

Frequent user

18 Feb 2011, 08:48

Dear Casie,

You are absolutely correct. Of course, in emergencies, including wasted breastfeeding mothers in SFP to support them is fully warranted. But there is no hard evidence that food supplements are of any help for non wasted women who just have breast-feeding problems. I would think some workers are ready to do anything to "help" breastfeeding mothers, even in absence of evidence. And, as you said, it is much easier to give food supplements than to do proper breastfeeding counselling. I suspect this maintained breastfeeding women with breastfeeding problems in SFP programmes despite lack of evidence that it has any effect on milk production. Breast feeding counselling would be much more appropriate.

Malnutrition of the lactating mother can however have an impact on child nutrition. It is often assumed that breast milk is a perfect food and provides everything, even if the mother herself is malnourished. This is not totally true. Most nutrients in breast milk are well maintained even if the mother is deficient but for some other nutrients, such as vitamin D or essential fatty acids for instance, breast milk will not be sufficient to cover the needs of the child if the mother doesn't have these nutrients in sufficient amounts in her diet. See a review of this for micronutrients in:

Allen LH. Maternal micronutrient malnutrition: effects on breast milk and infant nutrition, and priorities for intervention. SCN News. 1994;(11):21-4.

But even if the mother is deficient in some micronutrients, this is unlikely to translate into insufficient breast milk production, rather in decreased content in breast milk with subclinical functional consequences such as increased susceptibility to infections for vitamin D or sub-optimal brain development for EFA.

Michael Golden

Normal user

18 Feb 2011, 16:19

I completely agree with Andre. However, there is a twist in the tail. All the nutrients whose concentration drops in breast milk when the mother has an inadequate intake are type 1 nutrients: what this means is that the mother (and breast milk) can be deficient without any anthropometric change in the mother. Indeed, the mother can be deficient and obese if she has been taking "empty calories".
A student, Vesna Markoska, examined breast milk of control and mothers of malnourished children in DRC and found that all the mothers had low concentrations of several critical type 1 nutrients (can send the thesis to anyone interested).
The implication is that selecting mothers to recieve supplements by anthropometry is not appropriate and that in such areas ALL lactating mothers should have a diet adequate in all the essential nutrients. How this should be done is another matter that needs explored.

Tamsin Walters

en-net moderator

Forum moderator

18 Feb 2011, 17:15

From Ali Maclaine:

Hi Mike, Thanks for this and thanks everyone for the discussion.

In IFE speak rather than focusing on maternal nutrition and its effect on the nutritient content or amount of breastmilk we tend to say that we ought to give nutritional support to the lactating mother anyway in order to protect her health as a priority as her reserves will be used to feed the baby and also to ensure that the mother-baby pair survives. (I think that there has been a focus on saving the infant with nutritional support rather than making sure that the mother is ok too; as you know motherless infants have a much lower survival rates, which feeds into the thought process). Ensuring that the mother has enough food to protect her health rather than the extra food having a big effect on the nutritional composition of breastmilk is a simple message in order to ensure that breastfeeding is not undermined as a life-saving measure. However, as brought up by you and others it is not always as simple as this and the effect on type 1 nutrients is a key issue. I would be very interested in reading the thesis and wondered if you could send it to me directly - or maybe it could be put on the ENN IFE resource library for all to share as it is an issue that comes up a lot - ENN?

Another key issue I think that I don't think has come up yet (though I may have missed e-mails; I've just started as the new Vicky Sibson in Save and am amazed by her work-load, capacity and brilliance and am struggling to keep up already!) is the need for mothers to have adequate amounts of water to drink. The old message about breastfeeding mothers having 3 litres of extra water a day is now seen as being counter-productive for a number of reasons but making sure that she has enough to drink for thirst has been found to be key in ensuring enough volume of breastmilk and we all need to ensure that this happens.

Best wishes, Ali

Marie McGrath

ENN

Forum moderator

18 Feb 2011, 17:23

Mike, you make a very good point that was reflected in a write-up of experiences on infant feeding in Myanmar in Field Exchange (reference below). Save the Children describe how they got caught in a very difficult situation, where they did not feel it appropriate to admit non-malnourished mothers to SFPs for all the reasons given in the discussions so far. However the general ration was inadequate and it proved impossible to link women to the SFP. The lack of adequate food in general heightened the expectation for targeted food. One of the recommendations of the author is that shortfalls in general food aid should be addressed earlier in the response as there is a consequence for infant and young child feeding that is often not so explicitly recognised.

Victoria Sibson (2009). Putting IFE guidance into practice: operational challenges in Myanmar. Field Exchange, Issue No 36, July 2009. p31. http://fex.ennonline.net/36/putting.aspx

Sonia Khan

Normal user

19 Feb 2011, 04:49

Dear all,

I just want to congratulate all of you for the brilliant discussions on this topic and for the important information shared. The lack of adequate support to mothers with breastfeeding problems is a crucial issue that needs to be addressed in most countries.
My special greetings to Mike Golden, who have supported a training on MAM in Mozambique a long time ago.
My best regards,

Tamsin Walters

en-net moderator

Forum moderator

20 Feb 2011, 16:35

Dear all

The Vesna Markoska thesis is now available in the resource library on the ENN website, www.ennonline.net/resources/756

Mike has also kindly shared 4 other MSc/PhD theses that relate to this topic and more broadly to the prevention and treatment of SAM and they are also now available in the resource library. These are:

"Water requirements of malnourished children in extreme hot and dry environments", Jacqueline Conduah Birt, 1999. A study of water turnover in SAM children in Tchad which was conducted after many children had been identified with hypernatraemic dehydration and there were recorded deaths from "convulsions" which the staff had not diagnosed but assumed were due to encephalitis/menigitis. Water turnover was 1/3 of body water per day! It raised the question of whether in the Sahara there is sufficient water in breast milk for the infants. ALL studies that Mike is aware of have come from places in the tropics that are not as dry/desicating.

"Nutritional status and survival in the siege of Turmanburg-Liberia" by Kareem Daari, 1999. An experience in Liberia where many hundreds of SAM patients were treated only during the day with a very low mortality (16 deaths in about 900 patients). No drips were used, no ORS routinely etc, and no deaths were seen from hypoglycaemia without food overnight. This was part of the experience that led to the introduction of day-care (residential or non-residential) and put hypoglycaemia way down on the priority list for potential complications.

"Severe malutrition: going from emergency to post-emergency management", Elodie Marchand 2000. A study of the effect of handing over a TFC to either a local hospital (with medical staff turnover - no turnover of nursing staff) and a local NGO running day-care with a only one nurse and 3 volunteers.

"Management of severe malnutrition in Africa", Yvonne Grellety, PhD thesis 2000. A major piece of work that led to changes in the WHO (1999) protocol to pay attention to the critical points that caused mortality and simplify the rest of the treatment.

Please contact me via post@en-net.org.uk if you experience any difficulties accessing these documents.

Many thanks
Tamsin


Casie Tesfai

Normal user

20 Feb 2011, 19:03

Dear all,
I really appreciate all of your responses and for the references you've shared. Mike, I would also love to read that thesis. And Marie, I have used the IYCF integration into CMAM guidelines in the last two countries I've worked with much success, so also let me thank you for that.

I'm still in a dilemma however for how all this translates into the field. Ali you said, 'Ensuring that the mother has enough food to protect her health rather than the extra food having a big effect on the nutritional composition of breast milk is a simple message in order to ensure that breastfeeding is not undermined as a life-saving measure.' In theory, I think we all agree, but in practice, what I've seen is that this 'simple' message does seem to undermine breastfeeding. Many mothers in resource poor settings where I've worked feel that if they are not eating a 'good' diet, their breast milk will not be adequate and this is often accompanied by an actual insufficiency caused by a breastfeeding problem (and the child loses weight, etc) which furthers this belief of 'not having enough milk.' Even most health workers would agree with this. From my experience, this is a major barrier to exclusive breastfeeding, and I wonder that even in the absence of an optimal maternal diet in a resource poor setting wouldn't exclusive breastfeeding still be the better option for the health and survival of the infant? I think your point Ali is often not misunderstood well enough in the field as it is translated as good diet= good breast milk production (and vice versa) which is undermining exclusive breastfeeding and mothers are looking for other solutions to supplement their breast milk.

So then I ask you, what would be a simple message for health/nutrition workers and mothers to target this barrier to exclusive breastfeeding? Could we not say that 'even if your diet is 'poor', you will still have enough breast milk.' But then the dilemma remains regarding the nutrients in the breast milk and how to promote a good maternal diet without undermining exclusive breastfeeding.

Thanks

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