Overview of the infant and young child feeding policy environment in Pakistan: Federal, Sindh and Punjab context.

BACKGROUND: Appropriate infant and young child feeding (IYCF) practices have been identified as important for appropriate child growth and development. (Ministry of Planning and Development, Ministry of National Health Services, Regulations and Coordination (2012)) Children in Pakistan still experience high rates of malnutrition, indicating a likely need for stronger IYCF policy. The purpose of this study was to identify major stakeholders who shape the IYCF policy environment and analyze which policies protect, promote and support IYCF practices, either directly or indirectly. METHODS: This study was conducted at the federal level, and in the provinces of Sindh and Punjab. We identified policies relevant to IYCF using a matrix developed by the South Asian Infant Feeding Research Network (SAIFRN), designed to capture policies at a range of levels (strategic policy documents through to implementation guidelines) in sectors relevant to IYCF. We analyzed the content using predetermined themes focused on support for mothers, and used narrative synthesis to present our findings. For the stakeholder analysis, we conducted four Net-Map activities with 49 interviewees using the Net-Map methodology. We analyzed the quantitative data using Organizational Risk Analyzer ORA and used the qualitative data to elucidate further information regarding relationships between stakeholders. RESULTS: We identified 19 policy documents for analysis. Eleven of these were nutrition and/or IYCF focused and eight were broader policies with IYCF as a component. The majority lacked detail relevant to implementation, particularly in terms of: ownership of the policies by a specific government body; sustainability of programs/strategies (most are donor funded), multi-sectoral collaboration; and effective advocacy and behavior change communication. Data collected through four Net-Map activities showed that after devolution of health ministry, provincial health departments were the key actors in the government whereas UNICEF and WHO were the key donors who were also highly influential and supportive of the objective. CONCLUSION: This analysis identified opportunities to strengthen IYCF policy in Pakistan through increased clarity on roles and responsibilities, improved multisectoral collaboration, and strong and consistent training guidelines and schedules for community health workers. The current policy environment presents opportunities, despite limitations. Our Net-Map analysis indicated several key government and international stakeholders, who differed across Federal and Provincial study sites. The detailed information regarding stakeholder influence can be used to strengthen advocacy.

Home-based rehabilitation of severely malnourished children using indigenous high-density diet.

OBJECTIVE: To evaluate the efficacy, cost-effectiveness and acceptability of a 'high-density diet made from indigenous ingredients. METHODS: The retrospective study was carried out from September 2009 to May 2010 in District Sanghar, Sindh, Pakistan. A field office was established and staff was recruited and trained. A baseline survey was done to screen for malnourished children aged 6-23 months using mid-upper arm circumference, for which a cut-off value of 115mm was adopted. The screened children with a weight-for-height z score <-3 were registered and were supplied the high-density diet and micronutrients. Their mothers were counselled on infant and young child feeding practices. RESULTS: The mean age of 123 children in the study was 15.5±8.5 months, and mean weight was 5.91±1.18kg. Overall, 85(69%) children attained the target weight in a mean duration of 5.08±3.2 months. Besides, 29(23.5%) children were gaining weight, but had not achieved the target by the end of the study. The mean rate of weight-gain of children who recovered was 3.30±3.59 g/kg/day. No significant adverse effects were noted. There was no documented refusal of the therapeutic supplement. The net cost of rehabilitating a child was $34.31. CONCLUSIONS: The high-density diet was reasonably efficacious in improving the nutritional status of severely malnourished children.

Effects of baby-friendly hospital initiative on breast-feeding practices in sindh.

OBJECTIVE: To determine changes in the breastfeeding practices of mothers after receiving counseling on 'Ten Steps to Successful Breastfeeding' as defined by the Baby Friendly Hospital Initiative comparing baby friendly hospitals (BFHs) and non-baby-friendly hospitals in Sindh, Pakistan. METHODS: The observational study was conducted from June 2007 to June 2009 in randomly selected baby-friendly and non-baby-friendly hospitals of Sindh, Pakistan. Non-probability purposive sampling was employed.The maternity staff was trained on 'Ten Steps to Successful Breastfeeding.'The changes in breastfeeding practices were analysed by SPSS version 15. RESULTS: A total of 236 women were included in the study. Of them, 196 (83.05%) were from baby-friendly hospitals and 40 (16.94%) from non-baby-friendly hospitals. Besides, 174 (88.7%) mothers in baby-friendly hospitals and 5 (12.5%) in non-baby-friendly hospitals during antenatal care received counseling by healthcare providers.There was an increase in breastfeeding practice up to 194 (98.97%) in the first category compared to 12 (30%) in the other category. CONCLUSION: Counseling under the Baby Friendly Hospital Initiative improved breastfeeding practices up to 98.97% in baby-friendly compared to non-baby-friendly hospitals.

Bilirubin pigments in the first meconium of newborn infants.

OBJECTIVE: To determine the pattern of excretion of total bilirubin IXa and IXb in the first meconium of newborn infants. METHODS: First two newborns of varying gestational age were selected every week through random sampling from the neonatal unit. Of the 41 newborn infants selected 8 expired before meconium passage, hence the results are from 33 newborns. Meconium was collected and stored at -20 degrees C, protected by aluminium foil. Samples were defrosted, vortex mixed with equal amount of dimethyl-sulfoxide, centrifuged, and analyzed by HPLC. RESULTS: Unconjugated Bilirubin-IXalpha and -IXbeta were identified and quantitative estimation of Bilirubin-IXa done. Bilirubin-IXb was greater than 50% of the total, in the first meconium of the newborn. Amount of bilirubin excreted in meconium was 29.2 - 90.8 mg [0.051 - 0.155 mmol] per sample of meconium passed. Amount was 9.7 mg/ Kg of body weight in term newborn and 12 mg/kg in preterm. CONCLUSION: The amount of bilirubin -IXb decreases and bilirubin-IXa increases with increasing gestational age. Newborns with birth asphyxia (BA) had significantly greater quantity of bilirubin in meconium, compared to infants without BA.