Breastfed Right: How Shrirampur’s Babies Escape Malnutrition
Poonam Phulpagar, 24, at her home in Ukkalgaon village in Maharashtra’s Ahmednagar district. Her youngest daughter, Khushi, at 1.5 months is a healthy 4 kg, thanks to health and nutrition counselling by the Shrimati Malati Dahanukar Trust. In contrast, at this age her second daughter Akshada, now two, was in the ‘severe acute malnutrition’ category because Phulpagar had subsisted on a diet of watery rice during her pregnancy and had not been counselled about breastfeeding.
Shrirampur, Mumbai (Maharashtra): Five years ago, Hina Shaikh, 28, delivered her second baby boy, a healthy 3.5 kg at birth. But within a week he had lost a kilo -- the infant simply refused breastmilk. Shaikh, who lives with her family in Shrirampur, an industrial town in Maharshtra’s Ahmednagar district, remembers being overcome by anxiety and guilt.
Shaikh was so distressed she stopped eating. “I felt it is my fault, that I am a bad mother,” she told HealthCheck.
It is likely that the baby, named Moin, would have continued to lose weight and, as is often the case, would have been moved to formula milk. This would have saved him from malnutrition but it could have led to two health risks in his adult life -- he would have weak immunity and would remain highly susceptible to metabolic diseases such as diabetes.
What saved Moin and Shaikh was a trip to a mother and child clinic run by Shrimati Malati Dahanukar Trust (SMDT) in Shrirampur, which is about 260 km north-east of Mumbai. Here, Shaikh learned a simple new breastfeeding technique -- the cross-cradle hold where the baby is held in the arm opposite the breast she/he is latched to.
Moin soon started gaining weight. Shaikh was also counselled about the right kind of foods her body needed during lactation, how to care for herself and how much to breastfeed. “I learnt I needed to breastfeed him 12 times in 24 hours, including four times at night,” she said.
For six months, she followed the clinic’s advice and fed Moin nothing other than breastmilk. Today, Moin is an active five-year-old, taller and better built than other Indian children his age. “He eats 2-3 chapatis everyday, loves non-vegetarian food and does not demand junk food,” said his mother.
Moin Shaikh, five years old, stands on a weighing machine at the mother and child clinic run by the Shrimati Malati Dahanukar Trust (SMDT) in Shrirampur in Maharshtra’s Ahmednagar district, as nurse Shila Borade looks on. Moin’s height and weight are above the Indian average for his age. The clinic advised his mother about the right kind of foods her body needed during lactation, how to care for herself and how much to breastfeed.
Impressed by Moin’s growth, when Shaikh conceived again two years ago, she sought out the same counsellors. Adherence to the technique right after birth meant that her second son, Rihan, was an even healthier newborn than his brother. At 14 months, he is taller and chubbier than children his age.
Moin and Rihan’s story is unusual in India where almost 40% of children below five years of age are stunted -- shorter height for age -- which is why the country is home to one-third of the world’s stunted children. Just about half of Indian children are exclusively breastfed, as recommended, until six months of age, as per the National Family Health Survey (NFHS-4). Also, less than 10% of children below two years of age get ‘minimum acceptable diet’ to meet their nutritional requirements.
A mix of strategies -- effective breastfeeding technique, homemade micronutrient powders to supplement baby food and improved maternal nutrition -- has helped the SMDT team bring significant changes in the life of Shrirampur’s children and their mothers, we found in our visit to Shrirampur.
The trust has counselled 510 women in six years and of the 399 mothers whose babies’ weights were known, 198 (49%) babies recorded a healthy birth weight of 2.5-3.5 kg, 123 (30%) of babies weighed more than 3.5 kg and only 78 (19%) weighed less than 2.5 kg.
A baby weighing less than 2.5 kg risks death, diseases, impaired growth and chronic disease later in life. Around 20% of babies in India weigh under 2.5 kg at birth.
The trust started as a corporate social responsibility drive initiated by Tilaknagar Industries, a distillery. The work to curb malnutrition among children began in 2013 under the guidance of paediatrician Rupal Dalal, who is now the trust’s director of health and nutrition.
So far the programme has helped about 1,800 children below two years of age and 1,580 children from three to six years. It has also counselled more than 500 pregnant mothers.
One of them is Poonam Phulpagar, 24, who has three daughters. Her youngest daughter, Khushi, at 1.5 months is a healthy 4 kg, while her second daughter Akshada, two years old, was in the severe acute malnutrition category when this age because Phulpagar was eating a diet of watery rice during her pregnancy and was not counselled on breastfeeding.
Why the focus shifted from infant to mother
Initially the nutrition programme used the conventional approach to the problem -- the staff identified children suffering from severe acute malnutrition (SAM) in neighbouring areas, brought them to the clinic and fed them ready-to-use therapeutic food (RUTF), a nutritional powder, until they gained weight. But once the children went back home, they returned to being malnourished. RUTF, by introducing children to sugar early in life, also seemed to put them off homemade food, while exposing them to the risk of metabolic problems.
Nutritionist Deepali Fargade from Shrimati Malati Dahanukar Trust counselling new mothers about the importance of breastfeeding at a maternity ward in Pravara Rural Hospital in Loni, 23 km from Shrirampur, in Maharashtra’s Ahmednagar district. The trust’s intervention has visibly improved children’s health in the area.
“We realised this was not going to work,” said nutritionist Deepali Fargade, who has been with the programme for over six years. “We stopped feeding children and decided to change our strategy and focus instead on counselling mothers.” Fargade, who manages the operations remains cheerful as she fields phone calls, handles logistics and shuttles between the clinic and her office on her scooter.
The trust had adopted 52 padas or village communities and decided to take its activities to the villages to save new mothers the trip to the clinic. For six days a week, a team of eight, including a doctor, a nutritionist, three nurses, two field officers, travel to different centres in a van equipped with weighing scales, growth charts, toys and teaching models. Every six months the team selects six to eight anganwadi centres—government-run childcare centres—and conducts activities there.
While the programme caters to children up to age six at anganwadis, its main focus is the first 1000 days of life—the time from conception to about two years of age. This period is called “the brain’s window of opportunity” by UNICEF because this is when the “foundations of optimum health, growth, and neurodevelopment across the lifespan are established”. This is the time when the brain develops the most and lifelong behaviour patterns are set.
The easiest breastfeeding technique is the least known
The first six months of a baby’s life when she is supposed to be exclusively breastfed are the most crucial too, said Rupal Dalal when HealthCheck met her at the Indian Institute of Technology (IIT) Bombay, where she is the adjunct faculty at the Centre for Technology Alternatives for Rural Areas (CTARA). The centre focuses on taking technology solutions to rural India.
Paediatrician Rupal Dalal, 48, is the director of health and nutrition at Shrimati Malati Dahanukar Trust, which started as a corporate social responsibility drive by Tilaknagar Industries, a distillery. It took her team 12 years to develop a programme focussing on the first 1,000 days of life to prevent malnutrition.
“Behaviour change is not as difficult as it is made out to be,” said 48-year-old Dalal. Slight and soft-spoken, her dedication to her task is fierce. “Yes, it needs consistency and perseverance but it isn’t rocket science.”
The first two years after the launch of the programme were tough when mothers were not sure what to make of the team and their counsel. But once the children’s health showed visible improvement, this changed.
“If mothers do nothing more than just breastfeed properly—forget maternal nutrition and protein- rich diets -- we can still help the children catch up [on normal growth],” Dalal said. This is because breast milk can compensate for poor intrauterine growth and if a baby grows well in the first six months -- when growth tends to be exponential -- she is likely to develop a healthy appetite, Dalal explained.
The problem is that mothers are often not counselled enough on how best to breastfeed. The technique most nurses and healthcare providers teach mothers is the traditional cradle hold wherein the arm holding the baby and the nursing breast are on the same side. Since babies fail to latch properly from this technique, they get less milk and their early growth is affected, Dalal said.
The team at SMDT teaches mothers to use the cross-cradle hold. If, for instance, the baby is latched to the left breast, she should be cradled in the right arm. The left arm may then be used to support the right from below. This facilitates closer contact between the baby and the mother and creates a closer latch.
(Watch a tutorial on the cross-cradle hold here )
Detailed instructions follow on how to place the baby’s mouth on the breast, how to use one’s fingers to express more milk, when to change sides and how to burp the baby afterwards. This is done through a visual guide as well as the use of baby doll and breast model.
We accompanied the team as they went to an anganwadi centre in the urban Motha Devi mandir area. Apart from their equipment, the team was also carrying the growth files of the children they were visiting. There is only one mother at the centre, 21-year-old Nisha Musale with her two-month-old baby boy, Swaraj. The boy was born a healthy 3.5 kg.
Field officer Anita Pachapind helping Nisha Musale breastfeed her two-month-old boy, Swaraj.
Musale started breastfeeding her baby within five minutes of a Caesarean section delivery, said field officer and nurse Anita Pachapind. Nutritionist Fargade quizzed Musale about how she gets ready to breastfeed. “I drink two glasses of water first, wash my hands and then get the baby ready for breastfeeding,” she responds, reeling off the preliminary rules she learnt to ensure that her baby gains about 40 gm every day.
The team usually visits an anganwadi centre every two weeks and the baby is weighed every time. “The tracking is very important, a baby has to gain about 1.2 kg each month and about 40 gm every day,” explained Dalal. “The weight tells us if the mother is feeding well, in the initial weeks she may not remember each of the 40 points explained during counselling sessions so we keep repeating them.”
The team uses the World Health Organisation’s percentile growth chart to trace a baby’s height and weight, and compare it with other children of the same age. It is a better scale than the Z score-- standard deviation units compared to international reference values--used by anganwadis that are late in detecting malnutrition, Dalal said.
The team wants local anganwadi workers and accredited social health activists (ASHA) to learn these tips so they can continue the work after the experts leave. “Our goal is not to sit there, our goal is empowerment,” said Dalal.
The ‘magic’ mix
When we visit Varsha Jadhav’s home in Motha devi mandir, 18-month-old Karthik was sitting shirtless on a bed while his older brother Prathamesh was being fed. “They haven’t taken a bath, I didn’t know you are coming,” Jadhav said as she saw the SMDT team walk in.
What did the SMDT counselling session six months ago teach Jadhav? “Karthik had to be hospitalised twice for pneumonia even before he was six months old,” she said. “After they counselled her, Karthik has gained weight. And he doesn’t even catch a cold now.”
The toddler’s diet now is a bowl of curd, roti-sabzi-dal (unleavened bread, and curried vegetables and lentils) and eggs.
Once they cross six months of age, babies often start losing weight because they are not introduced to the right kind of complementary foods. In fact, only 42.7% of children between six and eight months of age receive semi-solid foods with breast milk, as per NFHS-4. Also children between six months and two years of age who are being breastfed (8.7%) are less likely to get adequate diet than those not being breastfed (14.3%).
This is why counsellors at SMDT repeatedly emphasise the need for the right complementary foods for children.
“Mothers usually give dal water or rice water and cow’s milk to babies but this isn’t enough for growing children,” said Fargade. Counsellors teach mothers about foods rich in minerals and vitamins, especially micronutrients—pumpkins, cucumbers, cabbage, spinach, millet flour and eggs. They hold cooking demonstrations to show how easy it is to include one or more foods with varying nutrients in multigrain theplas (flattened bread), khichdi and dals (pulses).
Women are also taught how to make micronutrient powders for children using local ingredients such as black sesame, pumpkin seeds and flax seeds that are rich in zinc, magnesium and calcium, all necessary for bone and brain development: 100 gm of this mix delivers 600 calories and 55 gm of protein.
Amylase powder that helps convert starch into energy is also recommended. Made of germinated wheat, green gram and ragi, 100 gm of this powder delivers 360 calories and 12 gm of protein. Mothers are also encouraged to powder peanuts, coconut, flax seeds and black sesame, curry leaves and drumstick leaves for use in baby foods. Varieties of beans rich in potassium, folate and magnesium are also recommended.
(Recipes for nutritional powders here)
Dalal had once attended a talk by Michael Golden, the Irish malnutrition expert who helped formulate RUTF, in which he spoke of the body’s need for Type 1 and type 2 micronutrients. Type 1 micronutrients, which the body can store and use when needed, include calcium, vitamin B, vitamin D, iron. But Type 2 micronutrients such as zinc, magnesium and protein cannot be stored by the body and are essential for over 300 metabolic processes.
“The body has to survive and when it doesn’t get type 2 micronutrients through food, it breaks down the muscles to get them,” said Dalal. Type 2 deficiencies are also hard to diagnose.
Early lessons at pregnancy clubs
Given the importance of the first 1,000 days of life, the Shrirampur team tries to engage with the mothers during pregnancy through small clubs set up in anganwadi centres. Each week, the women sit through one-hour sessions on 17 topics that range from nutrition and foetal development to aches and pains and the importance of institutional delivery.
“My mother-in-law used to give me only dal water and told me not to eat non-vegetarian food when pregnant,” says Mumtaz Shaikh, 30. On counsellors’ advice, she started eating everything. Her second son Atif is now eight-month-old, a calm baby with a good appetite, whereas her elder son, Adnan, 5, who did not benefit from her improved diet, is underweight and a finicky eater.
“My mother-in-law used to give me only dal water and told me not to eat non-vegetarian when pregnant,” says Mumtaz Shaikh, 30, “but when I heard the counsellors, I started eating everything.” Her second son Atif is now eight-month-old, a calm baby with a good appetite but her elder son, Adnan, 5, who did not benefit from the programme is underweight and a finicky eater.
Non-vegetarian food is high in vitamin B12, zinc, iron and choline and bioavailable protein, and is therefore recommended for pregnant and lactating women. “About 82% of protein from eggs is absorbed in the body as compared to only 50% in pulses,” pointed out Dalal. In fact, she recommends all adolescents to get this information and eat better for giving birth to healthy children later.
Using technology and trainings to spread the message
Dalal’s, whose work on nutrition took 12 years to evolve, has worked in a government hospital in Mumbai before shifting to a non-profit, Foundation for Mother and Child Health (FMCH), based in Mumbai. She helped set up and headed the nutrition and health division there and during this period developed her strategy against malnutrition. From 2007 to 2018, her worked improved the health of over 10,000 babies in two urban low-income communities through FMCH, Mumbai and later 1500 children in the Shrirampur.
Vedika Joshi, 4 months, sitting on grandmother Madhuri Joshi’s lap, was born 3.87 kg, much heavier than the average for Indian babies. Her mother Dhanashree Joshi, 21 (left), is from Karnataka and watched Spoken-Tutorial videos to learn how to breastfeed and what diet to follow.
In 2017, she collaborated with Spoken-Tutorial, an initiative by IIT-Bombay professor Kannan Moudgalya to create free multilingual health and nutrition videos. These videos on breast-feeding and recipes for mothers have been translated into nine languages and viewed thousands of times and used for training.
IIT students are also in the process of analysing monitoring data of over 15,000 children helped by Dalal and her team and the impact of the intervention.
So far the SMDT team has instructed around 1,400 trainers of ASHAs, anganwadi workers and ANMs in many parts of the country.
Stunting is a condition that can be easily avoided and at no extra cost, stressed Dalal. “Indian children are by no means shorter than children in the west and if they are fed well, they too can thrive,” she said. “It’s my mission to give back the mothers this knowledge that has been kept from them.”
(Yadavar is a Principal Correspondent with HealthCheck.in and IndiaSpend.)
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