The neonatal period is the most vulnerable period for child survival. Although the neonatal mortality rate has declined over the years in Sri Lanka, we still have far to go in order to be on par with developed countries. Breast feeding is ranked the number one intervention for reducing neonatal mortality and most hospitals have taken measures to teach new mothers about the benefits, technique and what to do when trouble shooting during the antenatal period. Breast feeding is started within the first hour in all newborns with the support of the health staff. All mothers’ breastfeeding technique is checked and breast feeding supported until breast feeding is established. Baby’s weight is checked daily to detect excessive weight loss and thereby poor establishment of breastfeeding, says Dr. Nishani Lucas, Consultant Neonatologist, De Soysa Hospital for Women, in an interview with the Sunday Observer.
Excerpts of the interview:
Q. As a neonatologist, how do you compare the health status of newborns in Sri Lanka to what it was a decade ago? Has there been an improvement or a decline?
A. The neonatal period is the most vulnerable period for child survival. Globally, neonatal mortality rate has declined by 47% between 1990 and 2015 from 36 to 19 deaths per 1,000 live births. Newborn survival has improved significantly over the last decade, which is evident by the neonatal mortality rate of 11 per 1,000 live births in 2006 (National profile Sri Lanka 2010, UNICEF)which has dropped to 5.4 per 1,000 live births in 2015,way below the regional average for South East Asia (24.3) and on par with regional averages of Europe-6.0, Western Pacific-6.9 and the Americas- 7.7per 1,000 live births. (WHO 2015)
Q. Recent studies have shown that a significant proportion of infants suffer from malnutrition. These figures have been supported by the World Health Organization and UNICEF. Where are the highest pockets of malnutrition?
A. Highest pockets of malnutrition in Sri Lanka are found in the estate sector. The estate sector accounts for the highest prevalence of low birth weight, stunting, underweight and wasting. (Nutritional status in Sri Lanka, determinants and intervention: a desk review 2006-2011, UNICEF).
Q. Looking at statistics of hospital births how many infants per 100,000 population suffer from poor nutrition? Are there different levels of malnutrition in newborns?
A. Although malnutrition is commonly used as an alternative to under nutrition, it refers to both under nutrition as well as over nutrition.
Newborn malnutrition includes babies small for the gestational age i.e less than the 10th centile in weight for age, as well as large babies more than the 90th centile for gestational age. Underweight infants are defined as those with weight for age between 2SD and 3SD below the median according to the WHO growth standard. The percentage of underweight infants in Sri Lanka has reduced from 7.6% in 2013 to 6.9% in 2015, which would mean that about 27,600 infants suffered from under nutrition in 2015. (Family Health Bureau, Statistics, 2013-2015).
Overweight is defined as weight for height above 2SD above the median according to the WHO growth standards released in 2006. Although there was an increase in childhood obesity in under 5 year olds from 1978 to 2009 (1.7%) it has now declined to 0.6% in 2012 (WHO).
Q. What causes babies to be born malnourished? Is it inadequate nourishment they got while still in the mother’s womb? Early birth? Poor nourishment taken by the mother during her pregnancy? ( explain in detail)
A. Small for gestational age babies include those who are constitutionally small i.e healthy small babies who have reached their genetic potential (40%), those who are intrinsically small due to chromosomal or environmental influences i.e babies affected by Down syndrome, fetal alcohol syndrome, congenital infection, etc. (20%) and babies who are growth restricted due to maternal factors (40%).
Maternal medical conditions such as, hypertension, heart disease, diabetes, smoking, alcohol/substance abuse, uterine malformations, placental abnormalities and multiple pregnancies cause under nutrition in the baby
Low pre-pregnancy weight, maternal body mass index and gestational weight gain cause intra uterine growth restriction. Low maternal education as well as poor socioeconomic status account for increased risk of intrauterine growth restriction.Maternal micronutrient deficiency such as, deficiency in iron, folate, vitamin B12, zinc, increases the risk of growth restriction in the fetus/newborn.Strenuous physical activity during pregnancy including standing more than 2.5 hours/ day in the 2nd and 3rd trimester and sleeping less than 8 hours a day increases the risk growth restriction, abortion and preterm birth. Large for gestational babies, are born mainly due to poorly controlled diabetes.
Q. Teenage pregnancies are on the rise. Does the age of the mother for the first birth count in reducing nutrition problems in the baby? Are children born to these under-aged mothers more at risk than older mothers?
A. Adolescent mothers are at higher risk of giving rise to small growth retarded babies. (WHO 2014). As adolescent mothers themselves are still growing it has been suggested that both mother as well as the offspring compete for the supply of nutrients. However, maternal age more than 35 years also increase the risk of growth restriction in the fetus.
Q. Can diabetic new mothers indirectly cause malnutrition in their babies?
A. Yes, diabetic mothers do cause malnutrition in the fetus.Mothers who develop diabetes during pregnancy are at risk of having large for gestational babies with hyper insulinism. These babies are at high risk of low blood sugar, low calcium levels, breathing difficulties, complications during the birth process and metabolic syndrome later in life.
Mothers who have diabetes at the time of conception will be at increased risk of diabetic vascular disease which may cause abnormal blood supply in the placenta causing fetal growth restriction, as well as, in the absence of abnormal placenta they will be at risk of giving birth to large for gestational babies as mentioned above.
Q. What is the most important preventive measure for malnutrition in a new born? Is it breastfeeding?
A. Yes it is. Breastfeeding is ranked the number 1 intervention for reducing neonatal mortality by reducing the deaths of 823,000 children and 20,000 mothers along with economic savings of US$300 billion each year. (Lancet January 2016)
Q. How does breastfeeding help improve the baby’s nutrition status?
A. Breast milk is the best milk for the newborn as it provides the optimal nutrition.
Although all mammals make milk for their young, it is specie specific and tailored to meet the needs of that particular specie. Cow’s milk is high in protein resulting in rapid weight gain but sub optimal brain growth, whereas human milk has the highest amount of lactose in milk compared to all other mammals which results in the highest brain growth in the animal kingdom.
It results in breast fed children having a higher IQ of 7-10 points compared to those who are fed formula milk. Breast feeding also reduces the risk of respiratory infections by 72%, diarrhoeal diseases by 64%, ear infections by 50%, necrotizing enterocolitis by 58% and sudden infant death by 38% in the first 2 years of life.
Breastfeeding also colonises the baby’s gut with friendly bacteria, whereas formula feeds will colonise the gut with harmful pathogenic bacteria. Breastfeeding also reduces the risk of atopy and asthma by 9% as well as, the risk of malocclusion of teeth by 68%.
It also reduces the risk of childhood leukemia.
Breastfeeding also has long term effects by early programming.
It reduces the risk of adulthood obesity by 26%, type 1 diabetes by 39% and type 2 diabetes by 27%. (Lancet 2016) Formula feeding your baby causes health risks worse than cigarette smoking! Breastfeeding also reduces the risk of breast cancer, uterine and endometrial cancer, anemia in the mother, and helps with the control of maternal diabetes.
It is the healthy way to regain your pre pregnant body shape back !
Q. For how long should mothers breastfeed their babies? Is there a specific time period?
A. Mothers should breast feed their babies until the baby weans itself from the breast.
A baby should be exclusively breastfedfor 6 months without any other food or drink except the prescribed medications.
This can be shortened to 4 months in the case of growth failure or the mother having to return to work, where complementary feeds are introduced at the end of 4 months.
Baby should continue to be breastfed until a minimum of 2 years although at a lesser frequency, preferably after the 3 main meals, after the introduction of complementary feeds.
In the event the baby stops breastfeeding after the introduction of complementary feeds, continue to give complementary feeds WITHOUT introducing formula milk.
Milk is not essential after the period of exclusive breastfeeding, its nutrients can be given in the form of other dairy products like yoghurt, cheese, curd etc.
Formula milk or powdered milk is not recommended at any age.
Q. It has been reported that more mothers are now breastfeeding their babies, (around 75% , I think) Why then do we have so many undernourished babies in this country?
A. Small is not equal to undernourished. As I mentioned, there are many reasons for small babies. The percentage of low birth weight babies is 11% (Family Health Bureau, 2015).
This has improved from 16% in 2012. (Medical Statistics Unit) Also, with improvement in the obstetric care and assisted reproduction techniques more and more preterm babies are surviving, they are small but not undernourished.
Only 40% of these small babies are undernourished. Under nutrition in the newborn is due to maternal factors which affect the intra-uterine period.
However, breastfeeding the baby will help reduce under nutrition in infancy which is 6.9% at present (2015).
Although we are good at initiating breastfeeding, we are not as good in maintaining breastfeeding.
This is mainly due to poor awareness that formula milk is harmful and is not a safe substitute.
Q. How soon should a new mother start breastfeeding her baby after delivery? The first milk (colostrum) is considered very beneficial for the baby .Why?
A. Baby should be breastfed during the first hour of birth. Baby should be put to the breast when he/she shows feeding cues – looking around, lip smacking, sucking, etc. Skilled health care workers help the mothers to initiate breastfeeding immediately after birth.
Colostrum is very high in immunoglobulins, which are proteins that protect baby from infections. This is very important to help baby to be protected from infection or fight against infection.
The newborn gut is sterile at birth. If colostrum is the initial food it will colonise the baby with good bacteria. If any other substance including formula is given it will colonise the baby with harmful bacteria.
Q. How long do you recommend a mother breastfeed her baby?
A. Exclusive breast feeding for a minimum of 4 months, ideally 6 months and continued breast feeding for a minimum of 2 years along with complementary feeding.
As mentioned earlier , complementary feeds may need to be started early in the case of growth failure or mother having to return to work at 4 months.
However, frequency of breastfeeding should be reduced following the introduction of complementary feeding and would be restricted to 2-3 times a day, once on full complementary feeds.