National Strategy on Infant and Young Child Feeding

NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 to 2010 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 1 Republic of Kenya Ministry of Public Health and Sanitation NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 2 Acknowledgements 5 Foreword 7 Abbreviations 10 1 Background 12 2 Introduction 13 3 Justification 15 4 Situation Analysis 16 4.1 Nutritional Status Infants and Young Children in Kenya 4.2 Infant and Young Child Feeding in Kenya 4.2.1 Infant and Young Child Feeding Practices 4.2.2 Policy and Legislative Framework 4.2.3 National Infant and Young Child Feeding Programme 5 Goals, Objectives, and Targets 24 5.1 Goals 5.2 Aims 5.3 Objectives 5.4 Targets 6 Strategic areas 26 6.1 Policies, Guidelines and Legislation 6.2 Promotion of Optimal Infant and Young Child Feeding Practices through Advocacy and Communication 6.2.1 Breastfeeding 6.2.2 Complementary Feeding 6.2.3 IYCF in difficult circumstances 6.2.4 Low Birth Weight and Preterm Babies 6.2.5 Children with Malnutrition 6.2.6 Sick children 6.2.7 Infant Feeding in Emergencies 6.3 Infant and Young Child Feeding in the Context of HIV 6.4 Planning, Coordination and Partnership Mobilisation the Health Care System (through the BFHI) 6.5 Monitoring, Reporting and Evaluation 6.6 Research on IYCF 6.7 Resource Mobilization (Financial, Human and Organisational) Contents NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 3 7 National Infant and Young Child Nutrition Strategy 34 Implementation Plan 8 Obligations and Responsibilities 46 8.1 Government 8.2 Non Governmental Organizations and Community Based Support Groups 8.3 International Organizations 8.4 Industries and Enterprises 8.5 Professional Associations, Ministries, Mass Media and Other Groups 8.6 Communities Annex 1: National Policy Guidelines on Infant and Young Child Feeding Annex 2: Code of Marketing of Breast Milk Substitutes Annex 3: Ten Steps to Successful Breastfeeding Annex 4: Data on Nutrition Status: Kenya Demographic and Health Survey (KDHS 2003), Multi-Indicator Cluster Survey (2000) and Kenya Integrated Budget Household Survey (2005/2006) Annex 5: HIV and Infant Feeding: New Evidence and Programmatic Experience (WHO Consensus Statements) Annex 6: Critical Nutrition Actions for People Living with HIV/AIDS Annex 7: Essential Nutrition Actions References 59 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 4 The Ministry of Public Health and Sanitation would like to thank all those who contributed to the successful completion of this Infant Young Child Feeding Strategy and the operational plan. We hope that these and many other partners will continue supporting the implementation phase of the operational strategy in order to attain the desired results. Special appreciation goes to the core team that worked tirelessly to draft and review this strategy comprising of staff from the Ministry of Public Health and Sanitation, Dr Anna Wamae, Head, Division of Child and Adolescent Health; staff from Division of Nutrition including Terry Wefwafwa, Head, Valerie Wambani and Linda Komen; Faith Thuite, University of Nairobi, Linda Beyer, Nutrition Specialist, UNICEF Kenya and Assumpta Muriithi, World Health Organization (WHO) Kenya, with other key technical contributors listed. The following institutions are acknowledged for their contributions: • APHIA II Partners • Catholic Relief Services • Centres for Disease Control and Prevention (CDC) • Kenya Food and Nutrition Action Network (KEFAN) • Kenya Medical Training College (KMTC) • Kenyatta National Hospital (KNH) • Ministry of Heath National Aids and Sexually Transmitted Infections Control Programme (NASCOP) • Network of Aids Researchers in Eastern and Southern Africa (NARESA) • UNICEF Kenya, Eastern and Southern Africa Regional Office (ESARO) and New York Headquarters • University of Nairobi (Departments of Community Health and Paediatrics) • WHO Regional Office for Africa (AFRO) • World Vision Kenya Acknowledgements NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 5 Anne Awori, Kenya Food Action Network (KEFAN) Jane Gathigia, Nutrition Manager, World Vision Faith Gitahi, Nutritionist, Kenyatta National Hospital Moazzeam Hossain, IYCF Technical Advisor, Nutrition, UNICEF New York Headquarters Margaret Kyenkya, Consultant, UNICEF East and Southern Africa Region (ESARO) Noreen Prendiville, Head, Nutrition Section, UNICEF Kenya Pam Malebe, Kenya Food Action Network (KEFAN) Rosemary Ngaruro, Head, Division of Nutrition, Ministry of Medical Services Saba Mebrahtu, Regional Nutrition Advisior, UNICEF ESARO Professor Rachel Musoke, University of Nairobi, Paediatrics Professor Ruth Nduati, University of Nairobi, Paediatrics Rose Opiyo, University of Nairobi, Community Health Charles Sagoe-Moses, Acting Regional Advisor, IYCF, WHO Regional Office for Africa (AFRO) Mary Wachira, Nutrition Manager, Ministry of Medical Services, National AIDS and STI Programme (NASCOP) Esther Waihenya, Kenya Medical Training College (KMTC) Ellen W. Irungu, Programme Officer, Division of Child and Adolescent Health, MOPHS List of contributors NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 6 Evidence for promoting child survival demonstrates that breastfeeding saves lives and that exclusive breastfeeding protects against common childhood diseases such as diarrhoea and acute respiratory infections. Further, breastfeeding has important long-term health benefits that include reduced risks of obesity, allergies, heart disease, diabetes, breast and ovarian cancer in women, and anaemia in women; it also facilitates child spacing. Support for breastfeeding will be essential to achieve Kenya’s targets for the Millennium Development Goals (MDGs) and child survival. Kenya has been a signatory to all the global conventions with a commitment to do everything possible to promote, protect and support optimal infant and young child feeding practices. These resolutions include the World Health Assembly Resolutions adopted since 1981 on regulating the marketing of Breast Milk Substitutes (WHA34.22), the 1990 Convention on the Rights of the Child, the International Labour Organization (ILO) convention for maternity protection and the Innocenti Declarations of 1990 and 2005, among others. Recent data indicates that exclusive breastfeeding is the most effective preventive intervention for ensuring child survival. It is estimated to prevent 13 per cent of all deaths of children under five years old.1 The introduction of appropriate complementary foods (after 6 months of age) is also a critical issue for child survival, and could save 6 per cent of all under-five deaths1. By combining these two interventions, as much as 19 per cent of child mortality could be prevented and chances of reaching the MDG target for reduction of child mortality and morbidity would be increased. In Kenya, poor breastfeeding and infant feeding practices contribute to more than 10,000 deaths per year. The challenges for child survival in Kenya remain enormous. Kenya ranks among countries with the highest high rates of under-five mortality. Exclusive breastfeeding rates at 6 months have declined from 3.5 per cent in 1998 (KDHS 1998) to 2.7 per cent in 2003 (KDHS 2003). In other words, less than 3 in every 100 Kenyan infants are exclusively breastfed for the first 6 months. The implication is that 97 per cent of Kenyan infants are being exposed, daily, to an increased risk of disease, and have lowered immunity because they are given foods and drinks other than breast milk before 6 Foreword NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 7 1 Jones, G., Steketee, R.W., Black, R.E., Bhutta, Z.A., Morris, S.S. and the Bellagio Child Survival Study Group, ‘How many child deaths can we prevent this year?’, The Lancet, Child Survival Series, 362:65–71, 2003. months of age. One of the reasons for the decline of exclusive breastfeeding in Kenya is the confusion brought about by the HIV pandemic. Over the last 20 years, Kenya lost out on gains that had been made to promote, protect and support breastfeeding with a dramatic decline in facilities that were ‘Baby Friendly’ from 70 per cent in 1994 to 5.7 per cent in 2003. Further, Kenya is one of the few countries that has not ratified the Code for Marketing of Breast Milk Substitutes of 1983. Kenya is renewing its commitment through adopting the 2006 WHO Consensus statements on HIV and Infant Feeding, which provides clarity on repositioning breastfeeding as the best option for mothers living with HIV unless replacement feeding is Accessible, Feasible, Acceptable, Safe and Sustainable (AFASS) (see Annex 5). The Ministry of Public Health and Sanitation (MoH) commits to revitalizing the Baby Friendly Hospital Initiative through training all health workers and strengthening prevention of mother-to-child transmission (PMTCT) service providers to ensure optimal nutrition for the infants, increase their chances of survival, growth and development, and minimize the risk of MTCT. Kenya has the expertise, the technical and programme knowledge, to rapidly improve infant and young child feeding (IYCF) indicators and to save lives of its young citizens. The Ministry of Public Health and Sanitation renews its commitment to create an environment that enables Kenyan women, families and communities to practise optimal IYCF. In order to improve child survival through strengthening a focus on infant and young child feeding, the MOPHS will: • Develop clear and consistent policies and guidelines, and build the capacity of the entire public and private health care system to implement them. • Work with the Attorney General and Minister of Justice and Constitutional Affairs to ensure enactment of a national law that protects optimal IYCF. • Advocate for implementation and enforcement of the Maternity Protection NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 8 Provision in the Employment Act 2007 in all sectors. • Promote optimal IYCF practices to decision makers, the public and through strengthening the quality of health care service provision to mothers, families, and communities. • Provide support for appropriate IYCF practices in HIV service delivery and emergency situations. • Revitalize the Baby Friendly Hospital in Kenya, following the WHO/UNICEF Global guidelines. • Support districts to implement key elements of the IYCF strategy and strengthen community support mechanisms. The strategy provides a mechanism for comprehensive and coordinated interventions for optimal IYCF and improved child survival. The Ministry of Public Health and Sanitation will provide leadership and coordination through collaboration with all stakeholders, other ministries, international agencies, and non governmental organisations towards the fulfilment of the objectives of this strategy. Signed Dr. S.K. Sharif, OGW, MBchB, M.Med, DLSTMH. MSc Acting Director Ministry of Public Health & Sanitation NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 9 AIDS Acquired Immune Deficiency Syndrome APHIA II AIDS, Population and Health Integrated Assistance Program (USAID) ARI Acute Respiratory Infections BCC Behaviour Change Communication BFCI Baby Friendly Community Initiative BFHI Baby Friendly Hospital Initiative BM Breast Milk BMI Body Mass Index CBO Community Based Organization CHANIS Child Health and Nutrition Information System CHEW Community Health Extension Worker CHW Community Health Worker C-IMCI Community Integrated Management of Childhood Illnesses CRS Catholic Relief Services DCAH Department of Child and Adolescent Health DHMT District Health Management Team DoN Division of Nutrition, Ministry of Health DRH Division of Reproductive Health EBF Exclusive Breastfeeding ECHO European Commission Humanitarian Aid Office FADUA Frequency, Amount, Density, Utilization and Active Feeding FBO Faith Based Organization GM Growth Monitoring HMIS Health Management Information Systems (Ministry of Health) HIV Human Immunodeficiency Virus IATT Inter-Agency Task Team IBFAN International Baby Food Action Network ICC Inter Agency Coordinating Committee IEC Information, Education and Communication ILO International Labour Organization IMR Infant Mortality Rate IYCF Infant and Young Child Feeding IYCN Infant and Young Child Nutrition KDHS Kenya Demographic Health Survey KEBS Kenya Bureau of Standards KEMRI Kenya Medical Research Institute Acronyms and abbreviations NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 10 KMTC Kenya Medical Training College LBW Low Birth Weight LMC Lactation Management Centre MoA Ministry of Agriculture MCSS Ministry of Culture and Social Services MoE Ministry of Education MoH Ministry of Health MCH Maternal and Child Health MoLF Ministry of Livestock and Fisheries MDGs Millennium Development Goals MOPHS Ministry of Public Health and Sanitation MPND Ministry of Planning and National Development MTCT Mother-to-Child Transmission (of HIV) NARESA Network of AIDS Researchers in East and Southern African NASCOP National Aids and Sexually Transmitted Infections Control Programme, Ministry of Health NGO Non-Governmental Organization NIFSC National Infant Feeding Steering Committee OP Office of the President PEPFAR President’s Emergency Plan for AIDS Relief (USAID) PHMT Provincial Health Management Team PLWHA People Living with HIV and AIDS PMTCT Prevention of Mother-to- Child Transmission (of HIV) RDA Recommended Daily Allowance ToR Terms of Reference ToT Trainer of Trainers UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session (on HIV/AIDS, 2001) UNHCR United Nations High Commissioner for Refugees USAID United States Agency for International Development WABA World Alliance for Breastfeeding Action WBFW World Breastfeeding Week WFP World Food Programme WHA World Health Assembly WHO World Health Organization NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 11 Appropriate feeding practices are of fundamental importance for the health, nutrition, survival and development of infants and children everywhere. The 1990s saw an upsurge of several worldwide efforts to achieve this goal. Examples of these are the Innocenti Declaration on Breastfeeding (1990), the World Summit for Children (1990), The Earth Summit (1992), the International Conference on Nutrition (1992) and the International Conference on Population and Development (1994). All agreed on the need to create the right environment for women to breastfeed their children. The World Alliance for Breastfeeding Action (WABA), a global network of individuals and organizations and the International Baby Food Action Network (IBFAN) were also formed during this period, and both continue to champion promotion of appropriate infant and young child feeding (IYCF) practices. Children have the right to access safe and nutritious food, and nutrition is a universally recognized component of the child’s right to enjoyment of the highest attainable standard of health. Poor nutrition among infants and young children results primarily from inappropriate feeding practices where the timing, quantity and quality of foods given to infants are often inadequate. Optimal breastfeeding and complementary feeding practices are essential to meet the nutritional needs of children in the first years of life. An analysis of child survival strategies (Lancet 2003) emphatically demonstrated that exclusive breastfeeding for the first 6 months and continued breastfeeding from 6–11 months are among the most effective preventive interventions in reducing child mortality. The two combined with appropriate complementary feeding from 6 months can reduce childhood mortality by up to 19 per cent, thus contributing significantly to attainment of the Millennium Development Goals (MGD 1). In Kenya, the HIV pandemic and the attendant risk of mother-to child transmission (MTCT) of HIV through breastfeeding continues to pose unique challenges to the promotion of breastfeeding, even among families without infected individuals. The country also experiences recurring drought related emergencies, and appropriate IYCF in emergency situations remains a challenge. This strategy derives from the Global Strategy for IYCF (WHO and UNICEF 2003), the Kenyan Policy Guidelines on IYCF (MoH 2000), the National Assessment of IYCF Policies, Programmes and Practices (MoH and WHO 2004), and the National Food and Nutrition Policy (GoK 2007 before parliament). It seeks to build on past initiatives and achievements in promoting optimal IYCF in the country. 1 Background NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 12 This strategy is intended to provide a strong mechanism and framework through which the government can influence in a comprehensive and coordinated manner accelerated action to improve IYCF practices in Kenya.2 The strategy derives from the broad principles of the Global Strategy on IYCF. Its full implementation will help reduce infant and young child morbidity and mortality in line with the National Health Sector Strategic Plan II in ‘Reversing the Trends’ and makes a strong contribution towards attainment of the Millennium Development Goals (MDGs) and Vision 2030 in Kenya. The strategy has been harmonized with the National Food and Nutrition Policy (pending parliamentary approval). It also draws from recommendations of the national assessment of IYCF Policies, Programmes and Practices in the country (2004) and from follow-on consultative meetings of IYCF stakeholders. Key strategic issues that will need to be addressed to improve IYCF practices in the country detailed in the implementation plan are: strengthening policies and legislation on IYCF including advocating for enactment of the code for marketing of breast milk substitutes into law; promotion of breastfeeding and complementary feeding; support for appropriate IYCF practices in difficult circumstances including infant feeding in the context of HIV; strengthening coordination and programming on IYCF — revitalization of the Baby Friendly Hospital Initiative (BFHI), strengthening community support mechanisms and developing a comprehensive communication strategy on IYCF; and supporting ongoing research and monitoring implementation of IYCF interventions at all levels. The strategy provides a framework for various sectors to contribute to the improvement of health and nutritional status of Kenyan children through improved IYCF practices. It was developed through a participatory and consultative process involving key IYCF stakeholders, steered by a technical working group under the auspices of the National Infant Feeding Steering Committee. A framework for implementation of the strategy is included in this strategy. Implementing this strategy calls for increased political will, public investment and a heightened awareness of the critical importance of IYCF among health workers, other professionals and community based care providers. Involvement of the government, families, communities, community based organizations (CBOs), in collaboration with international organizations and other concerned parties will ultimately ensure that necessary action is taken. 2 Introduction NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 13 2 WHO and UNICEF, ‘Global strategy for infant and young child feeding’, WHO, Geneva, 2003. and WHO, Implementing the Global Strategy for Infant and Young Child Feeding, WHO, Geneva, 2003. The strategy is divided into five broad areas as follows: • Background and situational analysis — this section provides an insight into the status of IYCF policy and legislative framework, practices and programmes in Kenya. Strategic issues deriving from the situational analysis are highlighted. • Justification, aims, objectives and national targets on IYCF-this section outlines the rationale for the strategy and specifies the desired goals and targets on IYCF for a three year period (through 2010). • Strategies — this section outlines the broad strategic areas incorporating strategic issues, objectives, outputs and specific activities. • Implementation plan — this section provides information on how the strategies will be implemented and highlights activities, outputs, responsible institutions, monitoring indicators and time frame. • Roles and responsibilities of the government, private sector and other partners in implementation of the strategy. The strategy is intended as a guide for action. It is based on accumulated evidence of the significance of IYCF during the early months and years of life for child development. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 14 Key indicators on IYCF have been on the decline over the past two decades in Kenya. Currently, exclusive breastfeeding rates at 6 months are less than 3 per cent and there are virtually no health facilities that are baby friendly. Only around half (52 per cent) of mothers who give birth initiate breastfeeding within an hour while complementary feeds are introduced too early to most infants. The poor practices are closely linked with weak programming on IYCF. A national assessment of IYCF Practices, Policies, Programmes and Practices conducted in 2004 cited lack of operational targets on IYCF and a national strategy as key constraint to effective programming on this issue in the country. The assessment report further identified key challenges and gaps in implementation of IYCF programmes at various levels. Key among these are weak coordination, few partners implementing IYCF programmes in the country, poor monitoring systems on IYCF and limited capacity on IYCF at all levels. The key strategic issues addressed in this strategy are derived from a situational analysis through the national assessment on IYCF and views from subsequent consultative meetings held with key IYCF stakeholders. Further, an assessment of infant feeding at selected prevention of mother to-child transmission (PMTCT) sites showed gross violations of the code and limited understanding of infant feeding within the context of HIV. It is envisaged that the strategy will facilitate more focused and coordinated programmatic approaches in addressing these issues. 3 Justification NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 15 4.1 Child nutritional status In Kenya, an unacceptably high number of children — 1.8 million — are classified as chronically undernourished. Chronic and acute malnutrition, micronutrient deficiencies and infectious diseases are prevalent, particularly among the rural populations and the urban poor. Trends over the past 15 years have shown no significant change in the nutritional status of children under five years of age. In 1998, 33 per cent of children under 5 years were stunted, 22 per cent were underweight and 6 per cent were severely malnourished (KDHS). As per the 2003 Kenya Demographic and Health Survey (KDHS) 30 per cent were stunted, 20 per cent were underweight and 6 per cent were severely malnourished (see Annex 4). In Kenya, poor breastfeeding and infant feeding practices contribute to more than 10,000 deaths per year. 4 Situation analysis NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 16 Practices 1998 KDHS 2003 KDHS 1. Initiation of breastfeeding (% of babies breastfed within one hour of birth) 58% 52% 2. Exclusive breastfeeding (% of babies 6 months of age exclusively breastfed in the last 24 hours) 3.5% 2.6% 3 3. Duration of breastfeeding (median duration in months of breastfeeding of children under three years of age) 21 months 20 months 4. Bottle-feeding (% of breastfed babies 0–<12 months of age fed from bottles in the last 24 hours) 17.7% 27.6% 5. Complementary feeding (% of breastfed babies 6–<10 or 7–<10 months of age who received complementary foods in the last 24 hours) 94.8% 84.2% 4.2 Situation of breastfeeding and complementary feeding practices in Kenya 3 KDHS (2003) cites exclusive breastfeeding rates for < 6 months as 12.7 % although after a national stakeholder review of this indicator, 2.6 percent (which is also cited in KDHS for up to 5 months of exclusive breastfeeding) was agreed on as the figure for national reference. 4.2.1 Infant and young child feeding practices Breastfeeding Exclusive breastfeeding rates at 6 months have witnessed a decline from 3.5 per cent in 1998 (KDHS 1998) to 2.6 per cent in 2003 (KDHS 2003). This means that less than 3 in every 100 Kenyan infants are exclusively breastfed within the first half hour of birth and for the first 6 months. Exclusive breastfeeding is the most effective preventative intervention for ensuring child survival: it is estimated to save 13 per cent of all under-five deaths (see Figure 1 below). Exclusive breastfeeding protects against common childhood diseases such as diarrhoea and acute respiratory tract infections. It also has important long-term health benefits that include reduced risks of obesity and consequently heart disease, reduced risks of diabetes, reduced risks of breast and ovarian cancer in women, and reduced anaemia in women. However, with such a low proportion of children exclusively breastfed, this potential is not realized. The implication is that 97 per cent of Kenyan infants are being exposed daily to an increased risk of disease, and have lowered immunity because they are given foods other than breast milk before they are 6 months old. The introduction of appropriate complementary foods (after 6 months of age) is also a critical issue for child survival, and could save 6 per cent of all under-five deaths1. By combining these two interventions, as much as 19 per cent of child mortality could be prevented in Kenya, and malnutrition would be reduced. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 17 Figure 1: Under-five deaths that could be saved by preventive interventions Source: Jones, G et al, Child Survival Study Group. (2003) The Lancet, Child Survival Series; 362:65-71 The national public health recommendation is that infants should be exclusively breastfed for the first 6 months of life to achieve optimal growth, health and development. Virtually all mothers can breastfeed from birth provided they have accurate information and support from their families and communities. Optimal infant and young child feeding means that every infant/child should: • Be initiated with breastfeeding within half hour to one hour of birth. • Continue to be breastfed exclusively (no other food or drink) for the first 6 months. • From 6 months receive adequate quantities of and safely prepared nutritious complementary foods. • Continue to breastfeed for at least 2 years. This requires that every mother should be supported and helped by everybody around her to provide optimal feeding to her infant. She needs to: • Have the correct information about infant feeding and be fully aware and informed of the consequences on her well being and that of her baby of not initiating breastfeeding, of not breastfeeding exclusively for 6 months and of not adequately complementing breastfeeding. • Be protected by the law from any misinformation and from those who promote alternatives to breastfeeding. • Be taught and supported by whoever helps her to deliver to initiate exclusive breastfeeding within the first half to one hour after delivery and on discharge be fully reminded of how to establish and maintain exclusive breastfeeding for the first 6 months. • Have access to continued support during the first 6 months to breastfeed exclusively. In Kenya women contribute 60–80 per cent of the labour in household and productive activities particularly in the agricultural sector, with work hours longer than men. Male involvement with child care is poor in many communities. This contributes to inappropriate caring practices for young children. Programmatic interventions need to be put into place to create an enabling environment for women to breastfeed. The following have been identified as major issues/constraints to uptake of appropriate breastfeeding practices in the country. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 18 Gaps • Weak partnerships and coordination in promotion and support of breastfeeding at all levels. (Only a few community based organizations (CBOs), non-governmental organizations (NGOs) and faith based organizations (FBOs) are involved in promotion and support of breastfeeding.) • Inadequate knowledge on optimal breastfeeding practices among mothers, families and communities. • Widespread belief among mothers and other caregivers that breast milk alone is not adequate to support proper growth of infants in the first 6 months of life. • Inadequate capacity building of health workers on HIV and infant feeding resulting in a decline in promotion and support of breastfeeding in health facilities due to fear of maternal to child transmission (MTCT) of HIV through breast milk. • Inadequate capacity building of health workers on IYCF (pre and in-service) leading to insufficient promotion and protection and support of breastfeeding through health care facilities. • Inadequate support for breastfeeding mothers. • Social and cultural beliefs and practices affect appropriate infant feeding • Lack of community support groups that promote optimal IYCF linked to health facilities. • Lack of documentation and surveillance on breastfeeding performance in the country. • Weak implementation and poor monitoring of IYCF programmes in the country. • Support for infant feeding in difficult circumstances not adequately addressed. Complementary feeding By 6 months, breast milk is no longer adequate to meet an infant’s nutritional requirements. From this age, complementary foods that are nutritionally adequate should therefore be provided — in addition to breast milk. Breast milk continues to be an important source of vital nutrients, fluids and it offers immunological protection. Giving complementary foods too early or too late are both detrimental to child health. In Kenya, complementary foods are introduced as early as the first month and by 6 months 84 per cent of infants are already receiving complementary feeds. Unfortunately, these supplementary foods which replace breast milk are low in energy and micronutrients. This coupled with unhygienic preparation and storage conditions predisposes many infants to diarrhoea and inadequate diets causing a negative impact on growth and development which is very characteristic of this age group in NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 19 Kenya. There is also widespread promotion and use of inappropriately constituted cereal and legume mixes. Guidelines for quality control of food-to-food fortification of infant foods will be necessary to regulate this. Complementary foods should meet the basic criteria of frequency, adequacy, dense (enough), and utilization and active feeding (FADUA). The following were identified as the key issues/constraints that need to be addressed to improve complementary feeding practices in the country. Gaps • Inadequate knowledge of optimal complementary feeding practices by caregivers. • Unhygienic preparation and storage of complementary foods. • Early introduction of complementary foods. • Widespread use of nutritionally inadequate complementary feeds, especially cereal based porridges. • Low feeding frequency making it difficult to meet energy needs of infants and young children. • Limited access to appropriately fortified complementary foods. • Lack of guidelines for quality control of food-to food fortification of infant foods. • Lack of standards to regulate and control complementary feeds. • Widespread promotion and use of inappropriately constituted cereal and legume mixes. 4.2.2 Policy and legislative framework To effectively promote, protect and support breastfeeding, countries are expected to implement supportive policies and legislation, key among which are: • Comprehensive policy guidelines on IYCF. • Legislation to give effect to the principles and aim of the international code of marketing of breast milk substitutes. • Legislation protecting and supporting breastfeeding among working mothers. Policy guidelines on IYCF In 1992 the Ministry of Health (MoH) issued the national policy guidelines on infant feeding providing guidance to facilities providing maternal and child health (MCH) and maternity services on how to promote, protect and support breastfeeding and adequate complementary feeding. In 2000, the policy was updated to cover infant feeding in the context of HIV. There has been new global guidance on IYCF and HIV that requires that the policy and the National NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 20 Guidelines on Infant and Young Child Feeding in the Context of HIV (MOH and UNICEF, 2004) be updated in line with the World Health Organization (WHO) Consensus Statement on Infant Feeding and HIV (2006). Protecting IYCF through the regulation of the marketing of infant feeding products Kenya, as a member state of WHO, voted for the International Code of Marketing of Breast milk Substitutes (WHA 34.22 1981) and was one of the first countries to implement the code at national level, by establishing regulations (Kenya Code of Marketing of Breast Milk Substitutes). The Code is voluntary, a standard with Kenya Bureau of Standards. Kenya has voted for all subsequent World Health Assembly Resolutions that have improved on the International code. Since 2002, Kenya has been working on a draft law to incorporate the World Health Assembly (WHA) resolutions. The draft code is being reviewed by stakeholders under the leadership of the Division of Nutrition (DoN) and the Division of Child and Adolescent Health (DCAH), MOPHS. Supporting IYCF through maternity protection Working women in both the formal and informal sectors should be facilitated to establish and sustain exclusive breastfeeding for the first 6 months, by being provided with adequate paid maternity leave and breastfeeding breaks. Countries like Mali, Sweden and Tanzania have established 6 months maternity leave in recognition of the critical role exclusive breastfeeding plays in reducing diseases in women (e.g. breast cancer); increasing spacing between births without the use of contraceptives; cutting down on health care costs; reducing mortality in children; enhancing brain development leading to improved performance in school; and reducing risks of obesity resulting in heart disease and diabetes in adults. The ILO maternity protection convention 2000 No. 183 recommends at least 14 weeks (98 days) of paid maternity leave. Kenya has amended the legislation to allow women to take maternity leave together with annual leave. There will be need for employers to fully implement this provision to support breastfeeding mothers. The following were identified as the main gaps/issues relating to the policy and legislative framework that need to be addressed to improve IYCF practices in the country. Gaps • Lack of a comprehensive IYCF policy. • Weak implementation and monitoring of the national IYCF policy guidelines. • Lack of IYCF strategy. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 21 • Lack of enforceable regulations/code for marketing of breast milk substitutes. • Lack of a strategy for monitoring code violation(s). • Lack of capacity for code monitoring. • Inadequate awareness among health care providers of their role in implementation of the code leading to gross violations, especially at PMCT sites. • Inadequate support of working mothers who are breastfeeding due to non compliance by some employers in granting the recommended maternity provision. 4.2.3 National Infant and Young Child Feeding Programme In 2004 (MoH and WHO), an assessment of the Policies, Programmes and Practices of Infant and Young Child Feeding was commissioned and conducted. The assessment identified weaknesses and recommended that a national programme focused on IYCF, and which included a high level of advocacy, was necessary if mothers and children were to receive adequate support for optimal breastfeeding and complementary feeding practices. This strategy has evolved from a response to that assessment. Breastfeeding is a cross-cutting issue. The success of an IYCF programme is measured ultimately by the percentage of women that manage to breastfeed as recommended. The programme should therefore be targeted at supporting women to practise optimal IYCF and to care for their children. It should be comprehensive, an integral part of the health care system, have adequate funding and provide for support at the regional and local levels. The following were identified as key gaps/issues relating to programming on IYCF that need to be addressed: • Lack of national targets on IYCF. • Majority (>95 per cent) of health facilities offering maternity services are not baby friendly. • Lack of harmonized curricula and training materials on IYCF. • Limited capacity building on IYCF at all levels. • No communication and advocacy strategy on IYCF. • No programme supporting or promoting IYCF at the community level. • Inadequate allocation and poor mobilization of resources for IYCF. • IYCF component within PMTCT weak. • Inadequate support for IYCF in difficult circumstances (emergencies, HIV and low NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 22 birth weight infants). • Lack of a national research advisory group on IYCF. • Few partners supporting or implementing IYCF programmes in the country. 4.2.4 Institutional framework for IYCF Currently, the Division of Nutrition of MOPHS is the focal point for implementation of the IYCF programme in the country. The division provides leadership in implementation and monitoring of the IYCF policy guidelines in the country. The focal person on infant feeding in MOPHS also serves as the breastfeeding coordinator in the country. The National Infant Feeding Steering Committee (NIFSC), which has multi sectoral representation, is an advisory body to the ministry on IYCF. Coordination of IYCF at the provincial and district level is the responsibility of Provincial Health Management Teams (PHMTs) and District Health Management Teams (DHMTs). Their roles include implementation, capacity building and monitoring/ evaluation of IYCF activities. Community level initiatives on IYCF are integrated in the newly developed MoH community health strategy that includes cIMCI (Community Integrated Management of Childhood Illnesses) implemented through Community Health Workers (CHWs) supported by Community Health Extension Workers (CHEWs). The following emerged as key gaps/issues that need to be addressed to strengthen the institutional framework on IYCF in the country: • The national committee on IYCF is not officially designated. • Weak coordination on IYCF at national, provincial and district level. • IYCF issues are not well articulated in district health plans. • Weak monitoring and evaluation of IYCF at all levels. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 23 5 Goals, objectives and targets 5.1 Goal To contribute to improved health, nutritional status, development and survival of infants and young children in Kenya. 5.2 Aim The objective is to improve the nutrition status of infants and young children through the provision of essential interventions. 5.3 Objectives • To ensure that policies and legislation that are supportive of IYCF are enacted and implemented. • To improve uptake of optimal breast and complementary feeding practices. • To promote and protect appropriate IYCF practices for infants and children in difficult situations. • To ensure appropriate nutrition of children born to HIV infected mothers and reduce the risk of mother to child transmission of HIV through breast milk. • To promote efficient implementation of interventions on IYCF through improved coordination and collaboration of partners in the country. • To strengthen the capacity of stakeholders, programme managers and health care providers with improved knowledge and skills on IYCF counselling. • To strengthen monitoring and evaluation of IYCF at all levels. • To strengthen research on IYCF and timely dissemination of findings to decision makers. • To improve awareness on optimal IYCF practices through advocacy and awareness creation efforts. • To specify roles and responsibilities of partners in promoting appropriate IYCF practices. • To establish coordination structures for collaboration on IYCF programme efforts. • To sensitize the public for improved knowledge on IYCF practices. • To integrate the IYCF strategy into the health system. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 24 5.4 Targets for 2010 Kenya will work towards attaining the following targets for the period 2008–2010: 1. National structures on IYCF strengthened to facilitate planning, coordination and advocacy for implementation of the strategy. 2. Current national policy guidelines on IYCF and national guidelines on Infant and Young Child Feeding in the Context of HIV (2004) will be updated in line with the WHO consensus statement on HIV and Infant Feeding (2006) and be disseminated nationally by 2008. 3. Kenyan national law regulating the marketing of foods for children under 3 years will have will be enacted by the end of 2008 and an enforcement and monitoring system will be in place by the end of 2009. 4. To ensure provision of support for breastfeeding mothers by employers under the Employment Act. 5. Sixty per cent of all health workers and 80 per cent of PMTCT service providers attend the IYCF Integrated Course by 2010. 6. The Baby Friendly Hospital Initiative will be revitalized in Kenya to ensure that the 75 per cent of mothers who deliver in a health facility are initiated on exclusive breastfeeding and receive the support and information necessary to help them continue with exclusive breastfeeding for 6 months. 7. Promotion of optimal IYCF practices to the public, to health workers and to other social service providers. A communication and advocacy strategy will be developed by April 2008. 8. A national monitoring and reporting system will be established to promote efficient implementation of interventions on IYCF by 2008. 9. Fifty per cent of the districts in the country will have strengthened IYCF programmes, transformed at least 80 per cent of health facilities to be baby friendly including establishment of community breastfeeding support groups to increase exclusive breastfeeding to 20 per cent by 2010. 10. Eighty per cent of mothers who are HIV positive receive counselling on infant feeding in the pre and post-natal period by 2010. 11. Reduce bottle feeding from 27.6 per cent to 5 per cent by 2010. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 25 6 Strategic areas The following nine priority areas were identified as being crucial for the attainment of the goal: • Policies and legislation on IYCF • Practices on IYCF • IYCF in difficult circumstances • HIV and Infant Feeding • Capacity building on IYCF • Communication and advocacy • Research on IYCF • Partnerships and coordination • Monitoring and evaluation of IYCF 6.1 Policies, guidelines and legislation on IYCF Objective To ensure that policies and legislation that are supportive of IYCF are enacted and implemented Outputs • National strategy on IYCF finalised and disseminated. • National policy guidelines on IYCF (2000) and National Guidelines on Infant and Young Child Feeding in the Context of HIV (2004) reviewed and updated. • Standards on complementary foods, inpatient feeding and feeding of infants and young children in institutions developed. • Health worker guidelines on IYCF reviewed and updated. • Guidelines for promotion of IYCF at community level developed and disseminated. Activities • Review and update the IYCF policy guidelines. • Accelerate enactment of the Code of Marketing Breast Milk Substitutes into law and develop guidelines for implementation. • Review/adopt the new guidelines for implementation of the baby friendly hospital initiative. • Review and adopt guidelines for community level promotion of IYCF. • Develop standards and regulations on complementary feeding. • Develop norms and standards on IYCF counselling/education service delivery. • Develop standards for inpatient feeding of sick children including therapeutic/supplementary feeding. • Adaptation of the new WHO growth standards training modules. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 26 6.2 Promotion of appropriate infant and young child feeding practices Objective To improve uptake of optimal breast and complementary feeding practices Breastfeeding Outputs • Information, education and communication (IEC) materials/job aids on IYCF disseminated to health workers for use in counselling. • Information packs to promote optimal breastfeeding at antenatal care contact points developed and disseminated. • Facility based groups on IYCF established at antenatal care contact points through negotiation with mothers. • All health facilities offering maternity services designated as baby friendly. • Periodic assessment and reassessment of facilities on BFHI status institutionalized. • More CBOs partnering in implementation of IYCF initiatives. • Community breastfeeding support groups established and linked to health care facilities. • Equipment and supplies for growth monitoring (GM) at community level available. Activities • Revitalize BFHI at health facilities offering maternity services countrywide. • Expand BFHI through initiation of a programme on baby friendly community initiative (BFCI). • Establish a referral system between health facilities and community level initiatives on infant and young child nutrition (IYCN). • Initiate health worker facilitated mother support groups on IYCF through antenatal care. • Establish breastfeeding support systems in work places and at community level. • Develop and disseminate fact sheets and IEC on exclusive breastfeeding to mothers and caregivers. • Promote appropriate maternal diets for pregnant and lactating mothers. • Set up lactation management centres at all provincial general hospitals. • Procure equipment and supplies for community based growth monitoring. Complementary feeding Outputs • Standards on complementary foods developed and disseminated. • IEC for promotion of appropriate complementary feeding developed and used in counselling. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 27 • Recipes of locally available complementary foods for each district documented. • Demonstration kits on preparation of nutritious complementary feeds available and in use. • Demonstrations on preparation of complementary foods held regularly in health facilities. Activities • Develop fact sheets and IEC for promotion of appropriate complementary feeding. • Promote appropriate care practices on complementary feeding. • Promotion of use of fortified fats and oils and fortified foods. • Strengthen nutritional supplementation for groups at risk. • Promote utilization of locally available enriched complementary foods. • Strengthen growth monitoring at facility and community level. • Integrate growth monitoring and promotion with breastfeeding support groups. 6.2.3 IYCF in difficult circumstances (Includes low birth weight babies, sick children, and children with malnutrition and in emergencies) OObbjjeeccttiivvee To ensure appropriate IYCF practices for infants and children in difficult situations. OOuuttppuuttss • Facility capacity for optimal feeding of low birth and preterm babies improved. • Capacity of institutions/ organizations to respond to needs related to IYCF in children with malnutrition strengthened. • Capacity of managers of organizations working in emergency situations on infant feeding guidelines in emergencies developed. 6.2.3.1 Low birth weight and preterm babies Activities • Build capacity of health workers for improved nutritional care and support for mothers of preterm and low birth weight babies. • Improve mode of feeding and follow up for low birth weight and preterm babies institutionally and at community level. • Improve facility capacity to ensure optimal feeding of low birth and preterm babies in health facilities. • Strengthen implementation of strategies for prevention of low birth weight, e.g. improved maternal nutrition/health and micronutrient supplementation for adolescent girls. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 28 6.2.3.2 Children with malnutrition Activities • Build capacity of institutions/organizations to respond to needs related to IYCF with malnutrition. • Lobby for availability and use of ready-to-eat local foods for management of malnourished children at facility and community level. • Improve screening at community level to facilitate timely referral and management through training of community health workers on case management and referral for malnourished children. 6.2.3.3 Sick children • Improve nutrition care services for sick children. • Improve provision of therapeutic feeds for sick children. • Build capacity of institutions and communities to respond to needs of nutrition related chronic diseases. 6.2.3.4 Infant feeding in emergencies • Sensitize/orient relevant organizations/institutions on use of guidelines on infant feeding in emergencies. • Support and monitor utilization of IYCF guidelines in emergencies. • Build capacity of managers of relevant organizations/ institutions on guidelines. • Ensure adherence to the code of marketing breast milk substitutes in emergency settings. 6.3 HIV and infant feeding Objective To ensure that all HIV positive mothers receive critical nutrition actions and that their infants receive essential nutrition actions to minimize the risk of MTCT (Annex 6 and 7). Outputs • Eighty per cent of PMTCT staff trained in Integrated IYCF Course. • National dissemination of counselling materials and job aids for Infant Feeding and HIV. • National service delivery framework strengthened to ensure continuum of care for HIV infected mothers and their infants. • National monitoring and evaluation framework strengthened to ensure standards of care achieved for HIV positive mothers. Activities • National scale up of training of PMTCT service providers on integrated IYCF. • Establishing of national PMTCT centres of excellence for mentoring of health care providers. • National stakeholder forum(s) to finalize Infant Feeding and HIV job aids and IEC materials and establish national standards for strengthening NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 29 continuum of care. • National monitoring and evaluation tools for infant feeding practices for mothers that are HIV positive are strengthened (e.g. 711, Baby Friendly PMTCT Services, Code monitoring of services providing replacement feeding, operational research IYCF and HIV). • Strengthen and scale up social mobilization and community based efforts for increased male involvement in infant feeding issues for HIV infected women. 6.4 Partnerships and coordination Objective: To promote efficient implementation of interventions on IYCF through improved coordination and collaboration of partners in the country Outputs • Child Health Inter Agency Coordinating Committee (ICC) guidance on IYCF strategy implementation. • National Infant Feeding Steering committee strengthened. • Stakeholders’ forum for IYCF established at national level and ToR developed. • National and community level partnerships for implementation of IYCF interventions strengthened. • IYCF issues integrated in the district stakeholders’ forum. • Resources mobilized for implementation of the IYCF strategy at all levels. Activities • The Child Health ICC to provide guidance in implementation of the strategy. • Strengthen the national technical committee on IYCN. • Establish stakeholders’ forum for IYCN at national level and develop ToR for the forum. • Strengthen community partnerships for implementation of IYCN interventions. • Accelerate integration of IYCF issues in the district health and nutrition committees. • Mobilize resources for implementation of IYCF strategy. 6.5 Capacity building Objective To improve awareness, knowledge and skills on IYCF among stakeholders, programme managers and health care providers Outputs • National training curricula and materials on integrated IYCF/BFHI reviewed and harmonized. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 30 • Training package and capacity for monitoring IYCF at all levels developed. • Training package for community health workers on IYCF using the social change/behaviour change communication (BCC) approach reviewed and adopted. • Capacity building of health workers (ToTs) on community dialogue, case management and promotion of health seeking behaviour. • IYCF component in pre service education curricula for relevant cadres strengthened. • National Trainer of Trainers (ToT) and health workers trained on the integrated IYCF/BFHI. • Capacity building for code implementation and monitoring scaled up. • Policy makers/programme managers and stakeholders sensitized on IYCF. • Community health extension workers and community resource persons trained on IYCF. • National ToTs and health workers trained on the new WHO growth standards. Activities • Harmonize national training curricula on IYCF. • Review and adopt the WHO/ United Nation’s Children’s Fund (UNICEF) integrated IYCF training course materials and the updated BFHI training and assessment tools. • Capacity building of national ToTs and district health workers on the new integrated IYCF and updated BFHI. • Strengthen the IYCF component in pre-service education curricula for relevant cadres. • Harmonize pre-serice cirricula for IYCF • Accelerate in-service capacity building of health care providers on IYCF/BFHI. • Review and adapt a training package for community resource persons on IYCF using the BCC approach. • Scale up capacity building for code implementation and monitoring. • Sensitize programme managers and stakeholders on IYCF. • Build capacity of CHEWs and community resource persons. • Develop training package and build capacity for monitoring IYCF at all levels. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 31 6.6 Monitoring and evaluation Objective To strengthen monitoring and evaluation of IYCF Outputs • Annual status report on implementation of the IYCF strategy shared with stakeholders. • Monitoring and evaluation framework for IYCF developed and implemented. • Monitoring and evaluation indicators and tools for IYCF reviewed and harmonized. • Software for IYCF developed and installed at national and district level. • Collection, analysis and utilization of Child Health and Nutrition Information System (CHANIS) data strengthened. • Implementation of the national communication strategy on IYCF monitored at all levels. • Data bank of all the persons trained on IYCF/BFHI/code developed and maintained. Activities • Develop a monitoring and evaluation framework for IYCF. • Review and harmonize monitoring and evaluation indicators and tools for IYCF. • Develop monitoring and evaluation tools for IYCF in difficult circumstances including HIV and Infant Feeding. • Develop software for IYCF for use at all levels. • Strengthen collection, analysis and utilization of CHANIS data. • Strengthen the IYCF component in the KDHS and other national nutrition surveys. • Improve data collection on IYCF in the early warning system and food security assessments. • Monitor and evaluate implementation of the communication strategy at all levels. • Maintain a data bank of all the persons trained on IYCF/BFHI/code. • Regular review of IYCF strategy implementation. 6.7 Research on IYCF Objective To support research on IYCF and timely dissemination of findings to decision makers Output • Priority research issues on IYCF identified and supported and findings disseminated. • Formative/operational research on IYCF undertaken. • Existing research on IYCF NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 32 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 33 documented and shared. • Report of baseline surveys shared. Activities • Support epidemiological and operational research on priority IYCF issues. • Undertake formative research to guide the development of the communication strategy. • Improve dissemination of research findings on IYCF to stakeholders. • Document and share existing research on IYCF. 6.8 Advocacy and communication on IYCF Objective Increased uptake of appropriate breast and complementary feeding practices through focused advocacy and awareness creation efforts Outputs • National communication strategy on IYCF developed and implemented. • Formative research to guide development of appropriate communication strategy on IYCF undertaken. • Communication for social change/BCC approach adopted in promotion of breastfeeding at community level. • Men/youth/religious leaders involved in the protection, promotion and support of IYCF. • World breastfeeding week /Malezi Bora (child/mother health and nutrition weeks) commemorated. • Advocates on IYCF identified and supported to undertake advocacy on IYCF. Activities • Develop a national communication strategy on IYCF. • Support a formative assessment study to guide development of appropriate communication strategy on IYCF. • Adoption of communication for social change/BCC approach in promotion of breastfeeding at community level. • Strengthen social mobilization activities on IYCF at all levels. • Advocate for involvement of men, youth and the community in protection, promotion and support of IYCF. • Support focused and sustained advocacy on breast and complementary feeding during world breastfeeding weeks and Malezi Bora (child/mother health and nutrition weeks). Identify advocates for IYCF 7. National Infant and Young Child Nutrition NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 34 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 35 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 36 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 37 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 38 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 39 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 40 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 41 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 42 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 43 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 44 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 45 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 46 8 Obligations and responsibilities The government, international organizations, development partners, NGOs, professional bodies, CBOs, FBOs, families and communities share responsibility for ensuring the fulfilment of the right of children to adequate health care and nutrition. Each partner should acknowledge and fulfil its responsibilities for improving the nutrition of infants and young children and for mobilizing required resources. All partners should work together to achieve the aim and objectives of the national strategy, through forming innovative alliances and partnership to avoid conflict of interest, duplication of efforts and to enhance effective use of resources. 8.1 Government • The government should support implementation of the strategy and operational plan at all levels. Adequate human, financial and organizational resources should be identified and allocated to facilitate timely and successful implementation of the plan. It is particularly important to have constructive dialogue and active collaboration with appropriate groups working for the protection, promotion and support of appropriate IYCF practices. • The government should enforce the maternity protection rights in line with ILO Maternity Protection Convention No. 183. and Employment Act 2007, Laws of Kenya • The government should accelerate efforts to enact the Kenyan Code for Marketing of Breast milk Substitutes into law and put in place monitoring mechanisms to ensure effective enforcement. • Government should spearhead revitalization of the BFHI countrywide. The integrated curriculum on implementation of BFHI in the context of HIV should be adopted and health service provider oriented in its use. BFHI needs to be integrated within the national health care system and provided with adequate resources to sustain it. • The National Consultative Group on Infant and Young Child Nutrition (NCGIYCN) should be strengthened to support implementation of the strategy and action plans. • The government should advocate and sensitize all stakeholders, i.e. health and other sector ministries, institutions and partners on the national strategy on IYCF. • Government should engage CBOs, FBOs and NGOs NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 47 operating in the community through monitoring and coordination of their activities. The linkage between the health facilities and the community should be strengthened through active engagement and collaboration. 8.2 Non-governmental organizations and community based support groups Diverse national and local NGOs, CBOs and FBOs have multiple opportunities to contribute to implementation of the operational plan on IYCF through: • Providing their members with accurate, up-to-date information on IYCF. • Integrating skilled support for IYCF in community based interventions and ensuring effective linkages with the nutrition and health care system. • Supporting creation of mother and child friendly communities and work places that routinely support appropriate IYCF. • Providing community based support including peer support through mother support groups, breastfeeding counsellors. 8.3 International organizations International organizations should place IYCF high on the global public health agenda due to its central significance in realizing the rights of women and children. They should serve as advocates for increased human, financial and institutional resources for implementation of the strategy. Specifically, international organizations should contribute to implementation of the action plan through: • Monitoring the BFHI and advocating for expansion beyond the maternity care setting. • Supporting social mobilization activities, for example using the mass media to promote appropriate infant feeding practices and educating media representatives. • Supporting improvement of women and child development and health workers skills in support of optimal IYCF. • Supporting national and regional capacity building of policy and decision makers on IYCF. • Support monitoring implementation of the code for and research on marketing practices of infant formula by commercial enterprises. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 48 • Revision of pre-service curricula for doctors, nurses, midwives, nutritionists, dieticians, auxiliary health workers and other groups as necessary. 8.4 Industries and enterprises Manufacturers and distributors of industrially processed foods intended for infants and young children have a constructive role to play in achieving the strategy. All manufacturers and distributors of products within the scope of the international code for marketing of breast milk substitutes are responsible for monitoring their marketing practices according to the principles and aim of the code. They should ensure that their conduct at every level conforms to the Kenyan code for marketing of breast milk substitutes. 8.5 Professional associations, ministries, mass media and other groups Identification of crucial complementary and mutually reinforcing roles for protection, promotion and supporting appropriate IYCF practices is very important. Many other components of the society have potentially influential roles in promoting appropriate feeding practices. Educational authorities: These help to shape the attitudes of children and adolescents with regard to IYCF. Accurate information should be provided through schools and other educational channels to promote greater awareness and positive perceptions. Mass media Influences popular attitudes towards parenting, child care and products within the scope of the international code for marketing of breast milk substitutes. Child care facilities which permit mothers to care for their infants. These should facilitate continued breastfeeding. 8.6 Communities Parents and caregivers are directly responsible for feeding children. Caregivers have a right to accurate information on feeding of infants and young children which they should be able to get from health care providers, and from community based support networks including mother support groups and lay and peer breastfeeding counsellors. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 49 NATIONAL POLICY ON INFANT AND YOUNG CHILD FEEDING PRACTICES MINISTRY OF HEALTH Summary Statement Every facility providing Maternal and Child Health (MCH) services should: 1. Adhere to the National Infant Feeding Policy, which should be routinely communicated to all health staff and strategically displayed; 2. Train all health care staff in skills necessary to implement this policy; 3. Provide information to all pregnant and lactating mothers and their partners on the benefits and management of breastfeeding; 4. Assist mothers initiate breastfeeding within the first 30 minutes of birth; 5. Give newborn infants no food or drink other than breast milk unless medically indicated (see specific guidelines on infants of HIV infected mothers); 6. Show mothers how to breastfeed and to maintain lactation even if they should be separated from their infants; 7. Practice rooming-in, allow infants to remain together with the mother 24 hours a day; 8. Encourage breastfeeding on demand; 9. Encourage and actively promote exclusive breastfeeding for infants up to six months; 10.Provide information and demonstrate to mothers how to introduce and prepare appropriate and nutritious complementary foods to their infants after six months; 11.Encourage mothers to breastfeed for at least 24 months (see guidelines for HIV infected mothers); 12.Foster the establishment of breastfeeding support groups and other support groups and refer mothers to them on discharge from hospital or clinic; 13.Not accept any free samples and supplies of breast-milk substitutes; 14.Not allow any publicity by the manufacturers or agents of breast-milk substitutes; 15.Not give any feeds using bottles or teats. Annex 1 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 50 HIV and Infant Feeding Pratices Guidelines A L L P A R E N T S • In fo rm at io n o n B e n e fit s o f B re as tf e e d in g • P re ve n tio n a n d M an ag e m e n t o f B re as tf e e d in g p ro b le m s* • A p p ro p ria te c o m p lim e n ta ry fe e d in g • P ro m o te g o o d m at e rn al n u tr iti o n a n d s e lf ca re • P ro vi d e V ita m in A S u p p le m e n ts , iro n f o lic an d Z in c • C o u n se l o n c h ild s p ac in g • P ro m p t tr e at m e n t o f in fe ct io n s • R e d u ct io n o f H IV in fe ct io n s • R is k o f m o th e r to c h ild tr an sm is si o n ( M T C T ) o f H IV • In fo rm at io n o n V o lu n ta ry co u n se lli n g a n d t e st in g • R e in fo rc in g r is k re d u ct io n to c o u p le V O L U N TA R Y C O U N S E L L IN G A N D T E S T IN G H IV V e M O T H E R S • R e in fo rc e r is k re d u ct io n • P ro m o te b re as tf e e d in g H IV + V e M O T H E R S • In fo rm at io n o n f e e d in g o p ti o n s • C o st o f o p ti o n s • In fo rm at io n & s ki lls o n h o w t o re d u ce /a vo id M T C T • A llo w t h e m o th e r & p ar tn e r to m ak e in fo rm e d c h o ic e M O T H E R S N O T T E S T E D • P ro m o te & s u p p o rt b re as t fe e d in g • E n co u ra g e & a va il in fo rm at io n o n vo lu n ta ry c o u n se lli n g & t e st in g • R e in fo rc e r is k re d u ct io n * * H IV + V e W H O C H O O S E N O T T O B R E A S T F E E D • D e m o n st ra te s af e p re p ar at io n & s to ra g e o f ch o se n m ilk • D e m o n st ra te c u p & s p o o n f e e d in g • C o u n se l o n t h e c ar e o f th e b re as ts t o av o id e n g o rg e m e n t • P ro vi d e r e lia b le f am ily p la n n in g m e th o d b y 4 w e e ks H IV + V e W H O C H O O S E T O B R E A S T F E E D • S u p p o rt & E n co u ra g e e xc lu si ve b re as tf e e d in g • P re ve n ti o n & M an ag e m e n t o f b re as tf e e d in g p ro b le m s • D is co u ra g e b re as tf e e d in g i f cr ac ke d n ip p le s, m as ti ti s o r A b sc e ss • P ro vi d e r e le va n t an ti re tr o vi ra ls * B re as tf e e d in g p ro b le m s (a b sc e ss , m as ti ti s, b re as t an d n ip p le d is e as e ) * * F o r w o m e n w h o h av e f e at u re s o f cl in ic al A ID S m an ag e a s H IV p o si ti ve NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 51 CODE OF MARKETING OF BREAST MILK SUBSTITUTES 10 IMPORTANT PROVISIONS Scope of the code The code applies to all products that are marketed to replace breast milk. These include formula, other milks, infant foods, teas or juices. The code also applies to feeding bottles and teats. The code seeks to encourage and protect breastfeeding by restricting aggressive marketing practices used to sell products for artificial feeding 1. No advertising of Infant Formula to the public 2. No free samples to mothers. 3. No promotion of products in Health Care Facilities 4. No company representatives to advice mothers 5. No gifts or personal samples to health workers 6. No words or pictures idealizing artificial feeding, including pictures on the labels of products. 7. Information to health workers should be scientific and factual. 8. All information on artificial feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards of artificial feeding. 9. Unsuitable products, such as sweetened condensed milk, should not be promoted for babies. 10. All products should be of high quality taking into account the climatic and storage conditions of the country where they are used. Annex 2 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 52 TEN STEPS TO SUCCESSFUL BREASTFEEDING Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in, i.e. allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Annex 3 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 53 1. Population (in thousands) 5412 % urban 16.3% Kenya Demographic and Health Survey 2003 report % rural 83.8% % children under 1 year 21.1% % children under 5 years 78.9% 2. IMR rate (per 1000) 77/1000 Kenya Demographic and Health Survey 2003 report 3. Low birth weight 9.3% Multi- Indicator Cluster Survey, 2000 4. Underweight (under-fives) 20.9% Kenya Integrated Budget Household Survey, 2005/2006 5. Wasting (under-fives) 6.3% Kenya Integrated Budget Household Survey, 2005/2006 6. Stunting (under-fives) 34.7% Kenya Integrated Budget Household Survey, 2005/2006 7. Prevalence of anaemia 43% Multi- Indicator Cluster Survey, 2000 (for pre-school and pregnant women) 8. Prevalence of use of iodized salt 91% Multi- Indicator Cluster Survey, 2000 9. Inadequate Iodine Intake based on Urinary Iodine Excretion Rates 24.9% Multi- Indicator Cluster Survey, 2000 10. Households with clean water supply 42% Kenya Integrated Budget Household Survey, 2005/2006 11. Diarrhoeal disease rate 0–5.9 months 9.9% Kenya Demographic and Health Survey 2003 report 6–11.9 months 12–23.9 months 20.3% 32.0% 12. ARI rate 0–5.9 months 10.4% Kenya Demographic and Health Survey 2003 6–11.9 months 14.9% 12–23.9 months 23.9% Kenya Demographic and Health Survey 2003 report 13. HIV prevalence among pregnant women Kenya Demographic and Health Survey 2003 14. Mothers with low body mass index 12.3% Kenya Demographic and Health Survey 2003 15. Maternal mortality rate (per 100 000) 414/100,000 Kenya Demographic and Health Survey 2003 16. Births attended by trained health personnel 39.1% Kenya Demographic and Health Survey 2003 17. Births in health facility 37.8% Kenya Demographic and Health Survey 2003 18. Total fertility rate 5.0 Kenya Demographic and Health Survey 2003 19. Contraceptive prevalence 38.3% Kenya Demographic and Health Survey 2003 20. Government expenditure allocated to health 6% Annex 4 DATA ON NUTRITION STATUS: KENYA DEMOGRAPHIC AND HEALTH SURVEY (KDHS 2003), MULTI-INDICATOR CLUSTER SURVEY (2000) AND KENYA INTEGRATED BUDGET HOUSEHOLD SURVEY (2005/2006) NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 54 HIV AND INFANT FEEDING: NEW EVIDENCE AND PROGRAMMATIC EXPERIENCE Report of a technical consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants, Geneva, Switzerland, 25–27 October 2006 (WHO, UNICEF, UNAIDS, UNFPA). Updated recommendations on HIV and Infant Feeding Based on the new evidence and experience, the group agreed on the following recommendations for policy makers and programme managers. These are intended to supplement, clarify and update existing United Nations guidance and do not replace it. An update of the relevant United Nations guidance incorporating these additional recommendations is available. • The most appropriate infant feeding option for an HIV-infected mother should continue to depend on her individual circumstances, including her health status and the local situation, but should take greater consideration of the health services available and the counselling and support she is likely to receive. • Exclusive breastfeeding is recommended for HIV-infected women for the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time. • When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV infected women is recommended. • At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, continuation of breastfeeding with additional complementary foods is recommended, while the mother and baby continue to be regularly assessed. All breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided. • Whatever the feeding decision, health services should follow up all HIV exposed infants, and continue to offer infant feeding counselling and support, particularly at key points when feeding decisions may be reconsidered, such as the time of early infant diagnosis and at six months of age. • Breastfeeding mothers of infants and young children who are known to be HIV infected should be strongly encouraged to continue breastfeeding. Annex 5 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 55 • Governments and other stakeholders should revitalize breastfeeding protection, promotion and support in the general population. They should also actively support HIV-infected mothers who choose to exclusively • Breastfeed and take measures to make replacement feeding safer for HIV infected women who choose that option. • National programmes should provide all HIV-exposed infants and their mothers with a full package of child survival and reproductive health interventions4 with effective linkages to HIV prevention, treatment and care services. In addition, health services should make special efforts to support primary prevention for women who test negative in antenatal and delivery settings, with particular attention to the breastfeeding period. • Governments should ensure that the package of interventions referenced above as well as the conditions described in current guidance [21] are available before any distribution of free commercial infant formula is considered. • Governments and donors should greatly increase their commitment and resources for implementation of the Global Strategy for Infant and Young Child Feeding and the United Nations HIV and Infant Feeding Framework for Priority Action in order to effectively prevent postnatal HIV infections, improve HIV-free survival and achieve relevant UNGASS goals. 4 UPDATED RECOMMENDATIONS ON HIV AND INFANT FEEDING For the full package of interventions, see: WHO, Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants in resource-limited settings, Geneva, 2006; WHO, The World Health Report: Make every mother and child count, Geneva, 2005. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 56 CRITICAL NUTRITION ACTIONS FOR PEOPLE LIVING WITH HIV AND AIDS (adapted from MOH, Kenya National Guidelines on Nutrition and HIV/AIDS, 2007) i Have periodic nutritional status assessments, especially the weight, at least every 2nd month for symptomatic clients and every 3rd month for asymptomatic clients. ii Increase energy needs for the disease stage through consumption of balanced diet. Severely malnourished patients (BMI<16) should be supported with therapeutic supplementary foods, where this is available. Patients with no AIDS symptoms require 10% more energy (one snack) per day than the recommended daily allowance for HIV-negative individuals of the same age, sex, physical activity level and physiological state. Patients with AIDS symptoms require 20-30% more energy (2-3 snacks) per day than the recommended daily allowance for HIV-negative individuals. Children with weight decline or faltering need 50-100% more energy than HIV-negative children of same age, sex. The additional energy can be achieved by consuming sufficient amounts of balanced food, including one or more snacks in between the meals in the course of the day, iii Maintain high levels of sanitation, food hygiene, and food/water safety at all times. If living in hookworm endemic areas one should be de-wormed bi-annually with an appropriate broad-spectrum anti-helminthic drug, like AlbendazoleTM or MebendazoleTM. iv Practice positive living behaviours, including practicing safer sex, avoiding or moderating use of alcohol, cigarettes and non prescription drugs, moderating consumption of junk foods, and management of depression and stress. v Carry out physical activity or exercises to strengthen or build muscles, increase appetite and health. vi Drink plenty of clean safe water (8 glasses in a day). All water used to swallow medicines and to prepare juices should be clean and safe (e.g. filtered and boiled). vii Seek prompt treatment for all opportunistic infections and other diseases, and dietary manage symptoms especially those that may interfere with food intake, absorption and utilization. viii Those on medicine, including ARVs, should manage the drug food interactions and side-effects by following the drug-food schedule, use dietary approaches to manage side-effect symptoms. If taking traditional remedies (herbs, medicines) or other nutritional supplements, the clinician should be informed. Annex 6 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 57 ix Children (below 6 months) born to HIV+ mothers whose mothers/caregivers have opted for exclusive replacement feeding, should be supplemented with 50,000 IU of Vitamin A and if not on commercial infant formula, put on multivitamins every day. WHO recommends consumption of one Recommended Daily Allowance (RDA) of all micronutrients (vitamins and minerals) all PLWHA. NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 58 ESSENTIAL NUTRITION ACTIONS (AED/LINKAGES) A set of seven proven interventions delivered at health facilities and in the community to improve the growth and micronutrient status of infants and children. These include exclusive breastfeeding, adequate complementary feeding, appropriate nutritional care of sick and severely malnourished children, and adequate intake of vitamin A, iron, and iodine. 1. Promotion of Breastfeeding 2. Complementary Feeding in addition to Breastfeeding 3. Feeding of the Sick Child 4. Women’s Nutrition 5. Control of Vitamin A Deficiency 6. Control of Anaemia 7. Control of Iodine Deficiency Disorders Annex 7 NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 59 Government of Kenya, ‘National Food Security and Nutrition Policy’, Sessional Paper, Nairobi, Kenya, 2007. Jones, G., Steketee, R.W., Black, R.E., Bhutta, Z.A., Morris, S.S. and the Bellagio Child Survival Study Group, ‘How many child deaths can we prevent this year?’, The Lancet, Child Survival Series, 362:65–71, 2003. Government of Kenya, 2007, Employment Act 2007. Laws of Kenya. Nairobi, Kenya. Ministry of Health, GoK, ‘Kenyan National Guidelines on Nutrition and HIV/AID’,, Ministry of Health, GoK, UNICEF Kenya, FANTA, USAID, Nairobi, Kenya, 2006. Ministry of Health (MoH), Government of Kenya, ‘National Policy on Infant and Young Child Feeding, Summary statement’, Nairobi, Kenya, 2000. Ministry of Health (MoH), Government of Kenya and United Nation’s Children’s Fund (UNICEF), ‘Curriculum Guidelines on the Baby Friendly Hospital Initiative in Kenya’, Nairobi, Kenya, 1999. Ministry of Health, UNICEF and WHO, The Code of Marketing Breastmilk Substitutes – Proposed Bill – 2008, MOH, Nairobi, Kenya, 2008. Ministry of Health, Government of Kenya and World Health Organization (WHO), ‘Report on Assessment of IYCF policies, programmes and practices in Kenya’, Nairobi, Kenya, 2004. Ministry of Planning and National Development, ‘Kenya Demographic and Health Survey’, Nairobi, Kenya, 2003. IBFAN (International Baby Food Action Network), ‘Protecting infant health — A health worker’s guide to the International Code of Marketing Breastmilk Substitutes’, 1987. UNAIDS, FAO, UNHCR, UNICEF, WHO, WFP, World Bank, UNFPA, IAEA, HIV and Infant Feeding: Framework for Priority Action, WHO, Geneva, 2003. References NATIONAL STRATEGY ON INFANT AND YOUNG CHILD FEEDING 2007 - 2010 60 UNICEF (United Nations Children’s Fund Eastern and Southern Africa Regional Office), ‘Status of young child survival and development in Eastern and Southern Africa’, UNICEF, Kenya, 2007. UNICEF and WHO, Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, UNICEF, New York, New York, 2006. WHO (World Health Organization), ‘Implementing the Global Strategy for Infant and Young Child Feeding’, WHO, Geneva, 2003. WHO (World Health Organization), Guiding principles for complementary feeding of the breastfed child, PAHO, Washington, D.C., 2004. WHO and UNICEF, ‘Global strategy for infant and young child feeding’, WHO, Geneva, 2003.