Neelam Kler Naveen Gupta Anup Thakur
2
in developing countries, mortality from malnu- trition, diarrhea and pneumonia increased sig- nificantly [3] .
The International Code
On May 21, 1981, the 34th meeting of the World Health Assembly adopted the fourth draft of the International Code of Marketing of Breast-Milk Substitutes as a minimum requirement to pro- tect and promote appropriate feeding of infants and young children [4] . This code was developed by the WHO and the UNICEF in partnership with governments, nongovernmental organiza- tions and the infant food industry. It was devel- oped to protect mothers and health workers
from commercial pressure by manufacturers of breast milk substitutes. It forbids provision of free samples to mothers or health facilities (ex- cept for professional research), because of their negative impact on breastfeeding. It also forbids inducements to health workers, because recipi- ents are more likely to promote a particular product and remain passive in promoting breast- feeding ( table 1 ). The code was passed by 118 votes to 1 (USA); 3 countries abstained (Argen- tina, Japan and Korea). By the 1996 World Health Assembly meeting, all 191 member states had affirmed their support for the code, its im- plementation and the implementation of rele- vant resolutions. By 1997, 17 countries had ad- opted all or substantially all of the code’s provi- sions as legal requirements. Adoption of the
Table 1. International Code of Marketing of Breast-Milk Substitutes [4]
Summary of articles
– There should be no advertising or other forms of promotion of the products – Manufacturers or distributors should not provide free product samples to mothers – Manufacturers or distributors should not distribute any gifts or articles to mothers – Marketing personnel should not seek direct or indirect contact with mothers – Facilities of the health care system should not be used for display of products
– No health care services should use professional service representatives provided or paid by manufacturers or distributors
– Health workers should encourage and protect breastfeeding
– Health professionals should be provided with scientific and factual information about the product
– No information to health workers should imply or create a belief that bottle feeding is superior to breastfeeding
– No material or financial inducements to promote products should be offered to health workers or members of their families
– Health workers should not give samples of infant formula to mothers or members of their families
– Labels should provide the necessary information about a product
– Labels should state the superiority of breastfeeding and provide information on appropriate preparation of a product
– Labels or the container should not have any picture or text that idealizes the use of infant formulae
– Labels should indicate the ingredients used, the composition, storage conditions required, batch number and date before which the product is to be consumed
– Monitoring the application of the code lies with the government, acting individually and collectively through the WHO
106 Kler Gupta Thakur
code represents the development of an interna- tional consensus. The code also covers ethical considerations and regulations for the market- ing of feeding bottles and teats. Even after 3 de- cades of implementation of the code there are continuing issues of implementation, monitor- ing and compliance, which predominantly re- flect weak governance [5] .
Violations of the Code
Since 1981, when the code was formulated, nu- merous violations have been reported both from the developing and the developed world. In devel- oping nations, multistage, random sampling of pregnant mothers and mothers of infants less than 6 months old was carried out in 4 cities (Dhaka, Durban, Bangkok and Warsaw) with dis- appointing results: 26% of mothers in Bangkok received free samples of breast milk substitutes from companies [6] . Many violations were re- ported in Uganda in a survey of mothers and health workers. In 2008, 70% of 427 health profes- sionals in Pakistan were unaware of their own breastfeeding laws, and 80% unaware of the code;
12% had received sponsorship from pharmaceu- tical companies for training sessions or atten- dance at conferences [7] . In countries with weak regulations, sales of formula were noticed to be higher. Differences were seen, for example, be- tween the Philippines and India. In India, where advertising is strictly controlled by the Infant Milk Substitutes Act [8] , breastfeeding rates are 46% at 5 months of age. In contrast, the Philip- pines, with much weaker regulations, have 3 times lower breastfeeding rates [9] . In the devel- oped world, marketing tends to be more subtle than in developing countries [10] . Among the in- dustrialized nations, the lowest breastfeeding rates (7% at 4 months) were seen in the UK, where companies spend 10 times more on advertising than the Department of Health spends on pro- moting breastfeeding. Interestingly, 20% of moth-
ers in the UK who were weaning their babies at 4–6 months of age thought formula was better and more nutritious than breast milk.
Monitoring the Code
Information provided by monitoring helps the WHO, UNICEF, governments and nongovern- mental organizations to imply the code and moni- tor violations. The reports on violations demon- strate the need for transparent, independent and effective controls in the marketing of baby food and bottles. Governments should ensure a consis- tent strategy of monitoring, involving investiga- tion, observation and recording of information.
The basics of monitoring include: familiarization with the main points of the International Code and with national measures; obtaining information on the breast milk substitutes locally used; recording details about the company and brand names and the hospitals/clinics where infant formula is used;
description of posters, displays, etc.; and reporting of violations to the appropriate body.
It is now recognized that voluntary initiatives alone are inadequate for implementation of the International Code of Marketing of Breast-Milk Substitutes. Health professionals and breastfeed- ing organizations call for enforcement of stricter rules. Under the international code, information provided by the manufacturers should not imply or create a belief that bottle feeding is equivalent or superior to breastfeeding.
Impact on Mortality and Morbidity
In developing countries, numerous studies have reported an increased mortality and morbidity with the use of breast milk substitutes. A recent meta-analysis showed excess risk of diarrhea mor- tality in nonbreastfed babies in comparison with exclusive breastfeeding among infants 0–5 months of age (relative risk: 10.52) and with any breast-
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 104–108 DOI: 10.1159/000360326
2
feeding among children aged 6–23 months (rela- tive risk: 2.18) [11] . Early initiation of breastfeed- ing is critical. In a Ghanaian study, neonatal mor- tality of babies fed after the first 24 h was more than twice that of those fed within the first hour.
In the developed world, exclusive breastfeeding has no detectable effect on mortality, but signifi- cant reductions in both short-term and long-term morbidity were noted. Failure to breastfeed in- creases the risk of gastrointestinal disease, acute otitis media and acute lower respiratory tract in- fection in infancy. In older children, the likelihood of obesity, elevated cholesterol levels, hyperten- sion as well as type 1 and type 2 diabetes is in- creased. In a recent meta-analysis, negative emo- tions such as guilt, anger, uncertainty and sense of failure were found more often in mothers of bottle-fed babies [12] . Term small-for-gestation- al-age babies are at risk of obesity and metabolic problems like hypertension and diabetes. Breast- feeding is protective by preventing accelerated growth in these subsets of babies [13] .
Situations in Which Breast Milk Substitutes Can Be Used
Formula feeding is clearly essential in certain cir- cumstances, such as when the mother is on cyto- toxic drugs or is unwilling to breastfeed. Since
HIV can be transmitted with breast milk, infected mothers were advised to use breast milk substi- tutes in 1985. This practice led to an increase in infant mortality in resource-poor countries where safe formula feeding was not feasible. Therefore, the WHO guidelines of 2010 recommend exclu- sive breastfeeding for the first 6 months with an- tiretroviral treatment of the mother unless substi- tute feeding is acceptable, feasible, affordable, sustainable and safe [14] .
Conclusions
• Breastfeeding is the best source of nutrition for infants less than 6 months of age
• Formula feeding can lead to increased infant mortality, especially in developing countries, due to poor hygiene and sanitation facilities • The risks of short- and long-term morbidities
such as infections, allergies, obesity and life- style diseases increase with formula feeding
• The International Code of Marketing of Breast-Milk Substitutes must be monitored and implemented in all countries. Health care professionals can play a very important role by explaining the benefits of breastfeeding to pregnant women and by promoting early ini- tiation of breastfeeding after birth
6 Taylor A: Violations of the international code of marketing of breast milk substi- tutes: prevalence in four countries. BMJ 1998; 316: 1117–1122.
7 Salasibew M, Kiani A, Faragher B, et al:
Awareness and reported violations of the WHO International Code and Paki- stan’s national breastfeeding legislation:
a descriptive cross-sectional survey. Int Breastfeed J 2008; 3: 24.
References
1 WHO: Infant and young child nutrition.
Geneva, WHO, 1993. EB93/17.
2 Palmer G: The industrial revolution in Britain: the era of progress? In Palmer G (ed): The Politics of Breastfeeding. Lon- don, Pinter & Martin, 2009, pp 205–207.
3 Jelliffe DB, Jelliffe EF: Feeding young infants in developing countries: com- ments on the current situation and future needs. Stud Fam Plann 1978; 9:
227–229.
4 World Health Assembly: Resolutions of the Executive Board at its sixty-seventh session and of the thirty-fourth World Health Assembly on the International Code of Marketing of Breast-Milk Sub- stitutes. Resolution EB67.R12 Draft In- ternational Code of Marketing of Breast- Milk Substitutes. Geneva, WHO, 1981.
5 Forsyth S: Three decades of the WHO code and marketing of infant formulas.
Curr Opin Clin Nutr Metab Care 2012;
15: 273–277.
108 Kler Gupta Thakur 8 The Infant Milk Substitutes, Feeding Bot-
tles and Infant Foods (Regulation of Pro- duction, Supply and Distribution) Act, 1992, as Amended in 2003 (IMS Act).
http://www.gujhealth.gov.in?images/pdf/
infant-milk-substitution2003.pdf (accessed July 30, 2013).
9 Sobel HL, Iellamo A, Raya RR, et al: Is unimpeded marketing for breast milk substitutes responsible for the decline in breastfeeding in the Philippines? An exploratory survey and focus group analysis. Soc Sci Med 2011; 73: 1445–
1448.
10 Coutsoudis A, Coovadia HM, King J:
The breastmilk brand: promotion of child survival in the face of formula- milk marketing. Lancet 2009; 374: 423–
425.
11 Lamberti LM, Fischer Walker CL, Noi- man A, et al: Breastfeeding and the risk for diarrhea morbidity and mortality.
BMC Public Health 2011; 11(suppl 3):
S15–S27.
12 Lakshman R, Ogilvie D, Ong KK: Moth- ers’ experiences of bottle-feeding: a sys- tematic review of qualitative and quanti- tative studies. Arch Dis Child 2009; 94:
596–601.
13 Singhal A, Lucas A: Early origins of car- diovascular disease: is there a unifying hypothesis? Lancet 2004; 363: 1642–
1645.
14 Ip S, Chung M, Raman G, et al: A sum- mary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries.
Breastfeed Med 2009; 4(suppl 1):S17–
S30.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 104–108 DOI: 10.1159/000360326
2 Nutrition of Healthy Infants, Children and Adolescents
Key Words
Complementary feeding ã Infant ã Breastfeeding
Key Messages
• Complementary foods are defined by the WHO as any food or liquid other than breast milk. However, since many infants receive human milk substitutes from the first weeks of life, other authorities have suggested that the term ‘complementary foods’
should be applied to foods and liquids other than breast milk or infant formulas
• Complementary foods are required for nutritional and developmental reasons. They should not be introduced before 17 weeks of age, but all infants should start complementary foods by 26 weeks of age
• It is important to ensure that complementary foods provide adequate energy density (minimum 25%
fat), and that the diet includes good sources of pro- tein, iron and zinc. Strategies used to achieve this will vary in different environments
© 2015 S. Karger AG, Basel
Introduction
Complementary foods are defined by the WHO as any food or liquid other than breast milk.
This definition means that infant formulas and
follow-on formulas (human milk substitutes, HMS) are regarded as complementary foods, which can be confusing, since many infants re- ceive HMS from the first weeks of life. Other authorities (European Society for Paediatric Gastroenterology, Hepatology and Nutrition, ESPGHAN [1] ) have suggested that the term complementary food should be applied to foods and liquids other than breast milk or infant for- mulas.
Complementary foods are required during the second part of the first year of life for both nutritional and developmental reasons, and to enable the transition from milk feeding to fam- ily foods. From a nutritional point of view, the ability of breast milk to continue to meet mac- ro- and micronutrient requirements becomes limited, whereas from a developmental per- spective, infants develop the ability to chew and start to show an interest in foods other than milk.
Current WHO recommendations on the age at which complementary foods should be intro- duced are based on consideration of the optimal duration of exclusive breastfeeding. However, since HMS are defined by the WHO as comple- mentary food, it is difficult to translate this rec- ommendation to formula-fed infants. Following a systematic review [2] and expert consultation
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 109–112 DOI: 10.1159/000360327