When the Answer is not a Bottle

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Title
When the Answer is not a Bottle
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SDA-RF-CH-1.19
OVERVIEW

When the answer is not a bottle
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In many parts of the developing world the incidence of
' infant malnutrition and diarrhoea can be directly linked
with a decline in breastfeeding, and its replacement by
wrongly and unhygienically constituted bottle-fed for­
mulas. PATRICE JELLIFFE describes the factors behind
^is trend, the efforts to evolve a code of conduct for the
marketing of infant formula, and some of the campaigns
underway to re-establish breast as best.
The problem of malnutrition among
infants and young children has been
emphasized by concerned health
workers and nutritionists for many
decades. However, the problem of
marasmus linked with the use of im­
properly administered infant formulas
has only begun to attract world-wide
interest in recent years. Careful scru­
tiny of the mechanisms leading to
mounting morbidity and an increasing
death toll among young children has
underlined the need for action pro­
grammes both at international and na­
tional levels to counteract faltering
trends in breastfeeding in many areas
^f the world.
^Around 10 million cases of infant
malnutrition, often accompanied by
diarrhoea, occur yearly in the develop­
ing countries as a direct or indirect re­
sult of a mother ceasing to breastfeed
Human milk is adapted to fit the needs of
her child. A number of social and eco­ each
individual baby. The absorption of
nomic trends have contributed to the minerals is superior, and breastmilk has
anti-infective
effects. ICEF 8749/Anand
problem. These include rapid urbani­
zation and its accompanying disrup­ able to obtain enough of the right food
tion of family life-styles, unemploy­ to provide a suitable diet for mothers
ment, and the low purchasing power and infants. But three main influences
among the poorest strata in society have accelerated the decline in breast­
which prevents families from being feeding and the parallel, and unprece­
E.F. Patrice Jelliffe is a lecturer and as­ dented, increase in infant malnutri­
sociate researcher in the Division of Popula­ tion.
tion. Family and International Health at the
School of Public Health in the University of
California; and co-author with Derrick B.
JeUiffe of Human Milk in the Modern World,
OUP1978.

The health profession
Health professionals’ lack of train­
ing in nutrition has now been recog­

nized worldwide, and breastfeeding
especially has been neglected. The
physiology of lactation and emphasis
on the important prolactin and sensi­
tive letdown reflexes are not stressed.
Nor are the dangers of separating the
mother and child at birth, and of intro­
ducing pre-lacteal feeds such as glu­
cose water or formula, which satiate
the newborn’s appetite and thereby
discourage the vigorous suckling
needed to assure successful breast­
feeding.
Training programmes have equally
omitted to point out the wide differ­
ences between the composition of
bovine and human milk, and that the
latter is adapted to fit the needs of each
individual baby; that the absorption of
minerals such as iron, zinc and calcium
is superior from human milk; and that
breastfeeding has child spacing and
anti-infective effects. In the light of
this lack of training and of the lack of
resources available for health care, the
health services have failed to assume
their responsibilities in the context of
breastfeeding and its relationship to
sound infant feeding practice. Thus
they have left open the field — a field
into which the infant food industry has
energetically stepped.

The food industry
For many years the manufacturers of
infant food products have been vig­
orously promoting milk formulas as
well as juices, cereal products and
pureed food for use in the early months
of life throughout the developing
world. Marketing practices have in­
cluded using company employees to
distribute free samples of milk to
mothers in hospital and on home visits,
as well as booklets, leaflets, and free
feeding bottles. These items are also
distributed to members of the health >

profession, although the literature va­ of marasmus is related to the increased
ries for each audience in terms of the availability of foreign milk products on
sophistication of the messages and the local markets, and that cases of infant
type of advice given. Many infant diarrhoea are now prevalent as infants
products are advertised in medical and do not benefit from breastmilk’s pro­
paediatric journals, and milk firms tective effect.
have a high visibility at paediatric con­
Working women and legislation
gresses. In certain quarters, the overall
impression reinforces the idea that bot­
In some developing countries, in­
tle feeding may be a simpler, more creasing numbers of women are enter­
modern and convenient method of ing the work force, professional
child feeding, and nutritionally equiva­ women with skills as well as others
lent to biological feeding.
employed in factories, in paid agricul­
It is recognized by the health profes­ tural jobs, in the construction industry
sion that under certain conditions, bot­ or as domestic servants. Some coun­
tle feeding may be necessary. If the tries have adhered to the International
infant is an orphan and no surrogate Labour Organization Conventions re­
lactating relative exists, if a mother is lated to working women. These allow
severely ill or does not wish to 12 weeks maternity leave, intended as
breastfeed, there may be no alterna­ six weeks prepartum and six postpar­
tive. But among the poorest and least tum, but which in many cases can be
knowledgeable strata within many taken at the woman's discretion, after
societies, bottle feeding is hazardous delivery if preferred, to ensure the es­
for the very young. Environmental tablishment of lactation. The conven­
sanitation standards may be very low, tions also establish lactation benefits,
and the importance of cleanliness and which entitle a working woman to take
sterilization ill-appreciated. It may two half hour remunerated nursing
also prove impossible for a low-income breaks during the day in breastfeeding
family to afford to buy sufficient for­ facilities (creches) on the premises or
mula to bottle feed a three-month old nearby.
infant with the mix at an adequate nu­
Many of these requirements al­
tritional concentration. This can cost though legislatively enacted are not
between 25 and 93 per cent of the adhered to by employers. Creches may
father’s daily working wage. Even in not be provided, or may be far away
situations where the family may be from the workplace, or preferential
able to afford adequate supplies of hiring of male employees may become
formula, it may be unhygienically ad­
Doctors recognize that in some cases bottle
ministered. A recent study by Autret feeding
may be necessary. But it is not
and Miladi in wealthy Arab countries nutritionally equivalent to breastfeeding
has shown that the frequent incidence ICEF 8748/Wolff

the rule. When creches are provided,
mothers may be hesitant to leave their
children in the unhygienic surround­
ings of an understaffed facility. Alter­
natively they may not want to travel for
several miles in an overcrowded bus in
which the risk of infection for the child
is high.

The clamour about
breastfeeding begins to grow
The difficulties encountered by
pregnant and nursing women have
been much emphasized in the last de­
cade. Health professionals and nut­
ritionists have drawn attention
through numerous publications to the
perilous condition of the bottlefed in­
fant in poor communities within de­
veloping countries. For 20 yeaigT'
(1950-1970) their work did not receivW
wide support, but by 1973/74 the World
Health Organisation (WHO) had begun
to give a much needed impetus to the
continuing battle to promote the ageold method of biological infant feeding.
During the 1970s mounting concern
began to be expressed both by mem­
bers of the health profession and by
consumer groups and voluntary ac­
tivists about the marketing practices
used in developing countries to pro­
mote infant formula and other foods.
The inducements to use infant feeding
products offered to members of the
health profession, such as the distribu­
tion of free samples for use by disad­
vantaged mothers, were among the
targets of the criticism. Some of the

UNICEF NEWS

OVERVIEW

The Code
A draft International Code of Mar­
keting of Breastmilk Substitutes has
now been forwarded by the Execu­
tive Board of WHO to the 34th World
Health Assembly, which in May 1981
will consider its adoption as a set of
recommendations. The following are
some of the key provisions:

eral public of products within the
scope of this Code.
© Manufacturers and distributors
should not provide, directly or indi­
rectly, to pregnant women, mothers
or members of their families, samples
of products within the scope of this
Code.

Health care systems

© There should be no advertising or
other form of promotion to the gen­

O The health authorities in Member
States should take appropriate meas­
ures to encourage and protect
breastfeeding and promote the prin­
ciples of this Code, and should give
appropriate information and advice
to health workers in regard to their
obligations.
© No facility of a health care system
should be used for the purpose of
promoting infant formula or other
products within the scope of this
Code. This Code should not, how­
ever, preclude the dissemination of
information to health professionals.
© The use by the health care system
of “professional service representa­

critics confronted the companies in
court, notably the Swiss activist group
Arbeitsgruppe Dritte Welt v. Nestle
(1974) and the Sisters of the Precious
Blood v. Bristol Myers (1976). These
cases attracted widescale publicity.
Clearly the time had come to try and
reach a concensus on the marketing of
infant formulas which could be agreed
to both by the health professionals and
by the food industry.
I The first joint meeting to discuss the
'issue had been convened in 1970 under
the auspices of UNICEF and the
Pan-American Health Organisation of
the UN system, and was held in
Bogota. It was followed by similar en­
counters sponsored by the UN Protein
Advisory Group, in Paris, New York,
Singapore and India. At the 27th World
Health Assembly (1974) a resolution
was passed which urged: “all member
nations to review the promotional ac­
tivities of baby food companies, to in­
troduce appropriate remedial meas­
ures including a new look at promotion
by advertising and the need to devise a
code of ethics for the firms.” Ross
Laboratories had already devised its
own code; ten other tompanies now
formed an International Council of In­

fant Food Industries (ICIFI) and for­
mulated another. Both these codes of
ethics are general in nature, and permit
wide interpretation in their applica­
tion.
By the end of the decade the promo­
tion of breastfeeding as one strategy to
combat increasing infant malnutrition
had become a subject, therefore, of in­
ternational concern. This led WHO
and UNICEF to co-sponsor an inter­
national "Meeting on Infant and Young
Child Feeding”, which was held in
Geneva in October 1979 and attended
by over 150 participants. These in­
cluded representatives from UN agen­
cies, from governments, the scientific
community, non-governmental agen­
cies, and the organizations and com­
panies of the food industry. The rec­
ommendations made at this meeting
have been carefully reviewed in
further consultations with the groups
concerned, and as a result, the fourth
version of a WHO/UNICEF Code of
Conduct on the marketing of infant
formulas has been forwarded by
WHO’s Executive Board with its en­
dorsement to the 34th World Health
Assembly to be held in May 1981. It will
be the prerogative of the governments

Information and education
© Governments should have the re­
sponsibility to ensure that objective
and consistent information is pro­
vided on infant and young child feed­
ing for use by families and those in­
volved in the field of infant and young
child nutrition. This responsibility
should cover either the planning,
provision, design and dissemination
of information, or their control.

The general public and mothers

UNICEF NEWS

tives”, “mothercraft nurses” or simi­
lar personnel, provided or paid for by
manufacturers or distributors, should
not be permitted.
• Feeding with infant formula,
whether manufactured or home-pre­
pared, should be demonstrated only
by health workers, or other commu­
nity workers if necessary; and only to
the mothers or family members who
need to use it; and the information
given should include a clear explana­
tion of the hazards of improper use.

Health workers
O Health workers should encourage
and protect breastfeeding; and those
who are concerned in particular with
maternal and infant nutrition should
make themselves familiar with their
obligations under this Code.

Labelling
O Labels should be designed to pro­
vide the necessary information about
the appropriate use of the product, and
so as not to discourage breastfeeding.

at the Assembly to accept the docu­
ment as a set of recommendations.

The promotion of breastfeeding
In many countries programmes to
promote breastfeeding are being insti­
tuted with varying degrees of effec­
tiveness. Much depends on factors
such as the existing legislative meas­
ures in force, the opportunities avail­
able for training, the resources and
personnel a country has available for
the programme, and the existence of
voluntary organizations such as
mothers’ support groups and con­
sumer advocates.
Before a breastfeeding campaign
can be effectively mounted, a commu­
nity diagnosis is needed as to prevail­
ing infant feeding practices. The
necessary information can be obtained
in conjunction with other on-going
surveys, into fertility or the prevalence
of diarrhoea, for example. A number
of prevalence studies on breastfeeding
have been undertaken in industrialized
countries and in developing countries,
as part of WHO’s collaborative study
on breastfeeding, or as part of national
or community studies.
>

OVERVIEW
Many variables have been exam­
ined, including pre-natal care, type of
delivery, time of the first breastfeed,
the use of pre-lacteal feeds, rooming­
in, and the management of breastfeed­
ing. Negative factors, which may in­
hibit successful lactation, have also
been studied: unnecessary sedation of
the mother, drugs given routinely to
stop lactation, the attitude of health
professionals, the role of food aid
which interferes with breastfeeding,
and family planning advice particu­
larly where lactation-inhibiting oral
contraceptives are involved.
In programmes dating from 1946-76,
workers concentrated their efforts ontesting the effectiveness of changing
certain hospital procedures. The care
of breasts (nipple retraction, preven­
tion of engorgement) was encouraged,
as was rooming-in, the education of
parents and midwives, and early skinto-skin contact. All of these proved
beneficial in helping mothers achieve a
more successful, and a longer, lacta­
tion period.

Towards a co-ordinated
infant nutrition policy
In order to promote breastfeeding
effectively, a co-ordinated infant nutri­
tion policy is required at government
level. This should include four main
components: a public education and
information campaign for profession­
als and the general public, using both
mass media and material locally de­
veloped for distribution to mothers'
groups; advisory services for mothers
in all relevant health facilities such as
pre- and post-natal clinics and mater­
nity and paediatric wards; legislation
in favour of pregnancy and lactation
benefits; and monitoring of the food
companies' activities by government
agencies and consumer groups.
In some countries, efforts are al­
ready underway to introduce some or
all of these components. A wide va­
riety of information and educational
literature has been developed in vari­
ous countries. As part of Thailand’s
national programme, for example,
competitions have been held to select
posters, songs,and poems which have
been widely disseminated throughout
the country. The Paediatric Associa­
tions of certain countries (USA,

tion by a suitably qualified practi­
tioner. Only breast milk is advertised.
The code of behaviour of both per­
sonnel from the food industry as well
Philippines) have strongly endorsed as that of health professionals must be
breastfeeding, and new textbooks scrutinized. Careful decisions must be
have been developed for health cadres. made at the highest political level re­
Mothers’ support groups have garding the importation arid marketing
played an important role in mobilizing of milk foods, fully realizing the impot^
women who wish to breastfeed but tant losses that a country incurs when
need information, encouragement and women of reproductive age, not ap­
support. Many such groups exist—La preciating the benefits of breastfeed­
Leche League International (USA), ing, elect to bottle feed. There is no
The Nursing Mothers of Australia, question that a considerable economic
Ammenhjelpen (Norway), PPI (Ma­ loss is sustained by their decision, not
laysia), Susu Mama (Papua-New to mention the costs of rehabilitation of
Guinea)—working closely with physi­ untold numbers of unnecessarily mal­
cians, and are well informed on clinical nourished children. A multiple strat­
problems which may arise in the man­ egy must be put into effect to reverse
agement of breastfeeding.
the declining incidence of breastfeed­
Some governments have banned the ing, not least important in which is the
advertising of infant formulas and no adherence of the food industry to the
longer allow milk company personnel WHO/UNICEF Code of Conduct. All
to visit hospital premises. In Papua these measures will play a significant
New Guinea, the sale of feeding bot­ part in whether “Health for All by the
tles, formula, nipples (teats), pacifiers Year 2000" becomes a reality for the
(comforters) is prohibited, and these youngest among us, or remains only a
items can only be obtained on prescrip­ dream.

Adequate nutrition should be ensured for
both pregnant and nursing mothers,
through advice and extra vitamins, miner­
als. and food. ICEF 7897/Satyan

UNICEF NEWS

Reprinted from: UNICEF NEWS. Issue 107/1981/1; by the International Baby Food Action Network (IBFAN), Geneva and Minneapolis
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