WHO/UNICEF Global Strategy for Infant and Young Child Feeding

Promotion, Protection and
Support of Breastfeeding
Dagmar Schneidrová
Department of Child and Youth Health
3rd Faculty of Medicine
Charles University Prague
Nutrition and Child Health
Infants and young children esp. sensitive
to external factors (e.g. nutrition)
First 2 years = a critical period for:
- growth and development
- health in infancy and childhood
- health in adulthood
Breastfeeding = a normative model
(American Pediatric Academy, 1997)
Breastfeeding is a preferred mode of feeding
considering benefits:
Health (morbidity, mortality)
Economical a ecological
Nutritional benefits of breast milk
Composition changes in the course of development
(preterm, fullterm infants), single feeding (foremilk,
hindmilk), in relation to exposure to infection (e.g. IgA)
Optimal concentration of nutrients, high
bioavailability, lower intake of calories
Growth factors – epidermal growth factor, hormons
Protective factors - immunoglobulins, lymphocytes,
leucocytes, macrophages, lysozym, bifidus factor etc.
Risks of artificial feeding
(in developing countries risks are elevated above these levels)
Increased risk of acute illness:
Gastroenteritis: 3-4x risk (developing countries
Acute otitis media: 3-4x risk
Lower respiratory tract infections (e.g.
Bacterial infection requiring hospitalization:
10x risk
Meningitis: 4x risk (e.g. Enterobacter
Higher mortality from sudden infant death
syndrome (SIDS)
Risks of artificial feeding
Increased risk of chronic conditions and
Allergies - atopic dermatitis, asthma
Type 1, type 2 diabetes
Crohn’s disease, ulcerative colitis, coeliac disease
Childhood lymphomas (5-8x risk), leukaemia
Risks of artificial feeding
Dose-related difference in mental development:
Lower scores of mental development tests at 18
Difference in mental development and school
performance at 3-5 years
Lower scores in prematures on intelligence tests
at 7-8 years
Deficits in neurological development (lack of
essential fatty acids)
Difference in visual acuity
Risks of artificial feeding
Effects on mother:
Increased risk of anaemia due to early
return of menstruation
Increased risk of new pregnancy
Higher risk of impaired bonding, abuse,
neglect and abandonment of the child
Increased risk of breast and ovarian
Breastfeeding and health of infants and mothers
(Agency for Healthcare Research and Quality, USA 2007)
Systematic epidemiological research :
43 studies on infants health
43 studies on mothers health
29 systematic metaanalyses (400 studies)
compared health outcomes in infants breastfed and
artificially fed (breast-milk substitutes) in
developed countries
Ip S, Chung M, Raman G, Chew P, Magula N, De Vine D, Trikalinos T, Lau J.
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.
Evidence Report/Technology Assessment No. 153. Agency for Healthcare Research
and Quality, April 2007.
Breastfeeding = lower morbidity
Nonspecific gastroenteritis
Necrotizing enterocolitis
Acute otitis
Infections of lower
respiratory tract
Sudden infant death (SIDS)
Atopic dermatitis
Asthma in young children
Diabetes (type 1, 2)
Child leukaemia
Diabetes (type 2)
Carcinoma of breast
Carcinoma of ovaria
Optimal Infant Feeding Practices
(WHO Global Strategy on Infant and Young Child Feeding, 2002)
Based on the evidence of
nutrition´s significance in the early
months and years of life
Lack of excl. BF during the first 6
months of life - important risk factor
for infant and childhood morbidity
and mortality (scientific and
epidemiological evidence –
www.ibfan.org - News Breastfeeding Briefs)
Optimal Infant Feeding Practices
(WHO Global Strategy on Infant and Young Child Feeding, 2002)
Exclusive breastfeeding for 6 months
Complementary feeding with continued
breastfeeding from 6 to 24 months and beyond
Appropriately fed
Acceptable medical reasons for use
of breast-milk substitutes (WHO, 2009)
Health problems in the infant
(WHO, 2009)
Contraindicatins of BF
- Galaktosaemia
(infant formula without
(below 1500 g)
Maple syrup disease
(infant formula without leucine,
isoleucine and valine)
Breastfeeding and
- Very low birth
(before 32nd week)
(infant formula without
Premature birth
(hypoxic stres, mothers
with diabetes, etc.)
Health problems in the mother
(WHO, 2009)
a) Contraindications of breastfeeding
HIV/AIDS infection
HTLV-1, 2 infection (India, Africa, Japan)
b) Temporary interruption of breastfeeding
Serious illness (e.g. sepsis)
Herpes simplex virus 1 infection (HSV-1)
Active TBC
Medication in mother (sedatives, antiepileptics, opioids,
radioactive iodine – J-131, cytotoxic chemotherapy)
c) Breastfeeding and management of the problem
Mastitis, abscess of breast
Hepatitis B, C, TBC (posit. tuberculine test)
Using addictive substances
Risks related to using
powdered infant formula (PIF)
WHO Study (35 countries)
- found patogens (Enterobacter sakazakii, Salmonella)
in 20% from 141 samples of PIF
- E. sakazakii – rare, but lethal cases of menigitis, NEC and
sepsis (40-80% mortality)
European Council for Food Safety and WHO (2007)
- issued guidelines for health workers and parents
– information on risk, hygienic preparation and proper use
of PIF products
Study at the 3rd Faculty of Medicine (2009) –
- survey at 10 hospitals (20 departments)
- found shortcomings in awareness of possible
contamination of PIF and its preparation
WHO/UNICEF Global Strategy for Infant and
Young Child Feeding (2002)
The goal - to improve the survival,
growth and development of children
during the first years of life through
protection, promotion and support
of early and exclusive
breastfeeding for the 6 months,
followed by continued BF for up to
2 years or longer with ageappropriate, complementary
feeding (www.who.int)
WHO/UNICEF Global Strategy
Guidelines for Implementation
Develop National Policy and
A national BF coordinator and a
multisectoral BF committee
BFHI (Baby-Friendly Hospital Initiative)
- all maternity services should fully practise
the Ten Steps to Successful BF
(www.who.int – BFHI)
Ensure multisectoral support for optimal
BF -provide consistent messages from all
WHO/UNICEF Global Strategy
Guidelines for Implementation
Support proper complementary feeding
Address exceptionally difficult situations
- HIV/AIDS, emergencies, etc.
Maternity Protection - legislation to
protect the BF of working women (ILO
Convention 2000/No. 183)
Support implementation of Internatinal
Code of Marketing of BMS and
subsequent relevant WHA Resolutions
Breastfeeding promotion in CR
(since 1991)
Collaboration with:
Professional organizations at national and
international level (WHO, UNICEF, IBFAN, LLLI):
* Education, training, publications, campaigns (WABA)
Ministry of Health, Parliament of the CR:
* Guidelines for health care based on BFHI (MoH)
* Law on advertisement (BMS)
* EU directives on marketing of BMS
National Lactation Centre (FTN Prague 4 - Krč):
* training lactation counsellors (800 health profs, 250
* evaluation of „Baby-Friendly Hospital“ (66 from 99)
The ten steps to successful breastfeeding (BFHI)
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
4. Help mothers initiate breastfeeding within one half 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 – 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.
Impact of marketing of BMS
(breast-milk substitutes)
Advertisements in antenatal clinics
(Howard, C. et al, 2000)
- associated with BF discontinuation in
first 2 weeks
- negative impact on BF duration in
women who decided to BF less than 12
weeks or did not decided about infant
Impact on marketing of BMS
(breast-milk substitutes)
Commercial hospital discharge packs
(Donnelly, A, Snowden DM, Renfrew MJ,
Woolridge MW (UK). Cochrane Database
Syst Rev 2000):
Research in medical electronic databases
Analysis of 9 clinical studies (3730 women
from North America) showed that:
- exclusive BF was reduced in the presence
of commercial hospital discharge packs
(preliminary introduction of complementary
Case study
(Prague maternity hospital)
Commercial discharge packs :
* Distributed by the company PROSAM to new mothers
upon the card filled with personal data, agreement with
further mailing of promotional materials
Hipp - sample of instant tea (from the 4th month)
- sample of complementary foods
Avent – promotion of aids for BF, bottles and teats
- bottle and teat
Happy Baby – information brochure on care for the
Happy Baby (brochure)
(Nutrilon, Milupa, Hamilon, Hami, Deva, Ben)
Advantages and disadvatages
commercial complementary foods
Saves time
Lower nutritional
value (compared to
fresh food)
Similar consistence
does not suit
developmental needs
of the infant
Costs money
Burden for the
(production, transport,
adverts, waste)
Complementary foods
(promotion versus WHO guidelines)
Promotion materials, labelling:
- instant sweetened teas from 1 week
- vegetable/meat and fruit mixes, juices,
instant cereals from 4 or 5 months
WHO guidelines (Global strategy,
complementary foods after 6 months
(early introduction – increased risk of
infections, allergies and caries, no
advantages in terms of weight gain)
Complementary foods
(World Health Assembly Resolutions)
WHA 1996 – CF should not be
marketed or used in ways that
undermine exclusive and sustained
WHA 1986, 2001 – product labels
and adverts should not state that
products are suitable in the first 6
WHA 2001 – recommends using
fresh nutritious foods
BF Protection Regulations
International Code of Marketing of
Breastmilk Substitutes (WHO, 1981)
Subsequent Relevant Resolutions of
EU Directive No. 141/2006
National legislation
(see - www.ibfan.org)
International Code of Marketing of
Breastmilk Substitutes (WHO 1981)
 Art.
4 Information and
 Art. 5 Public and mothers
 Art. 6 Health care systems
 Art. 7 Health workers
 Art. 9 Labelling
Art. 4.2 Information and educational materials
for pregnant women and mothers
Should be distributed via the health care system
Benefits and priority of breastfeeding stressed
Importance of healthy nutrition in mother
Negative impact of supplementation with a bottle
Health risks related to infant feeding
Instruction on proper use of infant formula
Financial consequences of artificial feeding
No texts, figures idealizing infant formula
International Code of Marketing of
Breastmilk Substitutes (WHO 1981)
Art. 6.2 – „No health care facility
should be used for promotion of
breastmilk substitutes, bottles
and teats…“
Art. 5.2 – „Distributors should not
provide samples of products to
Art. 7 Health workers
Should support and protect
Should not receive any financial or
material incentives for promotion of
Should not distribute samples of
products to pregnant women and
Art. 9 Labelling
„Important statement“:
 stressing priority of BF
 product use should be consulted
with health professional
 instruction on proper preparation
 warnig against health risks
 no texts or figures idealizing BMS
EU Directive No.141/2006
Regulations for promotion, labelling
and information on infant and followon formula in accordance with International
Code of Marketing of BMS
Prohibits free or low-cost products,
samples or gifts provided via health
Urges member states to transform
the directive into national legislation
Protection of BF in CR
Directive of MoH No. 54/2004
on foods for special purposes
(standards for composition and
labelling of BMS)
Law on advertizing
No. 138/2002 on infant feeding
Births in BFH and percentage of BFH (EU)
(Cattaneo, Romero, Lhotská, 2010)
Births in BFH
% of BFH
Excl. BF Infants in BFH, other hospitals
Long-term breastfeeding in CR (6 months
nad later)
(IHIS CR, 2010)
Počet dětí kojených 6 měsíců a déle v %
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
ÚZIS ČR 2010
Further reading
Infant and young child feeding: Model chapter for
textbooks for medical students and allied health
professionals. WHO, 2009 (http://www.who.int):
(Sessions 1,2,3,4,5,9, Annex 1,2)