Misunderstanding that we are doing enough for feeding infants and young children is a stumbling block to progress of nutrition in India.

The NFHS-5-phase-1 (Data from 22 States/UTs) revealed that 88% women deliver in hospitals, 51% are able to begin breastfeeding within an hour of birth, 61.9% breastfed exclusively during 0-6 months, 56% received timely complementary feeds at 6-8 months and only 16.1% received adequate diet during 6-23 months. Obviously 26.9% children are underweight, 31.9% stunted, 18.1% wasted and 5.5% obese. In 2024, the Modi government’s success will be judged against numbers of the India’s darkest distended underbelly, its millions of malnourished children. Answer lies in “putting one’s money where one’s mouth is”.
The Government of India accepts the scientific fact that breastfeeding can reduce 20% of the neonatal deaths. An international study estimates that India could prevent 100,000 child deaths and more than 37 million episodes of diarrhoea and pneumonia if breastfeeding were adequate. Other benefits include reducing obesity and increased IQ in children, reduced cancers and Type 2 diabetes in women who breastfeed. The WHO says that inadequacy of breastfeeding and complementary feeding has a direct impact on a child being underweight, stunted or wasted. However, the National Family Health Survey (NFHS) 5 data turned out to be a fiasco on indicators of feeding babies, which are immediate underlying determinants of nutrition. Phase 2 data may throw more light. I find it important to highlight now from birth to 2 years.

Breastfeeding at birth within
0-1 hour
Even as 88% mothers deliver in hospitals, only 51% are able to begin breastfeeding within one hour. Delivering a baby in the hospital seems to risk a baby’s first health vaccine. In fact there is a loss of 2.5-percentage points from NFHS-4 (2015). Reasons include dwindling care in the hospitals with maternity services, increasing caesarean sections and baby food company’s freedom to mingle with doctors and sponsoring their events. A World Bank study on Baby Friendly Hospital Initiative (BFHI) (2019) confirmed my assertions. “Despite the known benefits the challenges include (a) lack of ownership and funding of BFHI, (b) inadequate human resources, (c) overburdened health facilities, (d) weak monitoring and evaluation mechanisms, (e) inability to involve private hospitals, (f) ineffective implementation of the International Code of Marketing of Breastmilk Substitutes (the Code), and (g) lack of proper mechanisms to provide technical support and leadership. At the hospital level, separation of babies from mothers especially in cesarean section births, more so in the private sector; inadequately trained health staff; unnecessary use of infant formula due to commercial influence of baby food industry on health facilities; and inadequate counseling and support to mothers during antenatal and postnatal periods were some additional barriers to success of BFHI implementation.”

Exclusive Breastfeeding 0-6 months
Exclusive breastfeeding is all that a baby needs from 0-6 months is perhaps the greatest immunity booster. It is 61.9% with average gain of less than ½% per year, slow as compared about 1% point between NFHS-3 and 4. Reasons include lack of support from several sectors including health, WCD, Labour, NDMA, HIV, policy coordination and funding etc. Lack of or weak capacity of the health workers to support mothers during pregnancy, at birth, and later is responsible. Lack of funding for this intervention is a critical reason. The Government of India’s own guidelines recommend the need for a “lactation support staff” but the guidance is not accompanied by budgetary support. No wonder India ranks 79 among 98 countries on policy and programmes.

Introducing timely solid foods 6-8 months
There is an overall gain of 5% points on timely feeding over the past 5 years, going up from 50.9 to 56.0 in 18 States/UTs. There is a gain of 1% point each year. Nine States/UTs have shown a rise and other 9 have shown a decline. Only 4 states have shown an increase of more than 10% points (Dadar Nagar Haveli, HP, West Bengal, Tripura).

Adequacy of diet during 6-23 months
Only 16.1% children of 6-23 months are receiving adequate diet, which means breastfed children receiving 4 or more food groups not including the milk or milk products.
During the past five years this has increased by 2.4% points i.e. ½% per year. Reasons are non-availability of diverse food of 4 or more groups with the families who are poor, and lack of proper knowledge among others who have foods.

Implications of feeding fiasco on the Nutrition Status
If we believe WHO, “Increasing rates of exclusive breastfeeding can help drive progress against other global nutrition targets—stunting, anaemia in women of reproductive age, low birth weight, childhood overweight and wasting—and is one of the most powerful tools policy-makers have at their disposal to improve the health of their people and their economies”.
Feeding indicators have a direct bearing on the child’s nutrition status. The POSHAN Abhiyaan, Government of India’s flagship programme to improve nutritional outcomes, set a target for 2022 to reduce by 6% (2% p.a.) both the underweight and stunting. However, NFHS-5 reveals that progress is stagnant or worsening. Underweight is up from 25.6% to 26.9%, stunting is up from 30.9% to 31.9% and wasting has increased from 17% to 18.1%. Obesity (child overweight) has increased 3% to 5.5%; almost doubled.

How can India improve feeding indicators?
One of the key solutions is strengthening our policy and programmes. Health systems need deployment of adequately trained lactation support staff in the maternity hospitals and effective implementation of MAA programme through periodic assessment and awards/accreditation, enforcing the Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003.
At the block level it requires a deployment of 4 adequately trained staff members (lactation support staff and nutrition counsellors) to look after education on breastfeeding, complementary feeding, checking adequacy of diet, detection of early growth faltering and provision of variety of food to children. This group must be empowered to take action and provide data on a real time basis.

What will it cost to the exchequer?
• It may cost about INR 480,000 per hospital for support staff and INR 17-20,000 for assessment and monitoring.
• Investment at the field level is estimated to be about INR 1 CR per district for human resources and additional fund for diverse food where required for an individual child.
• Private sector should be asked to do it and spend its money in their business model of maternity package.
This intervention may change the scenario of breastfeeding within 3 to 5 years including in CS births. When early breastfeeding rates rise to match institutional deliveries, the degree of child malnutrition begins to fall.

Conclusion and way forward
It is disturbing to see how infants and young children are fed in India and a great concern that India’s nutrition indicators are stagnant. Feeding indicators are not up to speed. We cannot expect a rapid enough change in child nutrition. Post Covid-19 times call for urgent action. The POSHAN Abhiyaan may consider feeding indicators as an essential input. The Lancet series on the double burden of malnutrition recommends this as a double duty action.
The way forward is for the Government of India to establish an empowered “National Breastfeeding Commission” with an endowment of INR 1000 Crore to begin with as earlier committees set up for this purpose have failed to achieve their objectives. The commission should be empowered to take action, link with all states, and sectors including private. Need of its own plan and each state having its yearly plan is underlined. At the cost of repeating myself, I would say it again “Put your money where your mouth is”.
Dr Arun Gupta is a senior paediatrician, coordinator of Breastfeeding Promotion Network of India and regional coordinator South Asia for International Baby Food Action Network (IBFAN). IBFAN is a Right Livelihood laureate 1998.