READINGS IN INFANT FEEDING PRACTICES—1 Infant and Young Child Feeding

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Title
READINGS IN INFANT FEEDING PRACTICES—1
Infant and Young Child Feeding
extracted text
SAD-RF-CH-1.21

UNICEF
Regional Office for South Central Asia
73 Lodi Estate, New Delhi-110003

READINGS IN INFANT FEEDING PRACTICES—1
Infant and Young Child Feeding
The UNICEF Executive Director's Genera! Progress Report to the 1981 Session of the Executive
Board presents, inter alia, a wide-ranging and closely reasoned discussion on feeding practices
for infants and young children the world over. Reference EIICEFI681 (Part 11) Add. 2.

CONTENTS
Paragraphs

Summary
Importance of breastfeeding
I.
Development of breastmilk substitutes
Bonding
Advantages of breastmilk
Nutritional and physiological properties of human milk
Anti-infective properties
Other health benefits
Advantages of breastfeeding to the mother
Paediatricians' and public health recommendations for North America
Situations of poverty and underdevelopment
Supports required for breastfeeding
II.
Social status of women
Maternal nutrition
Current situation and recent trends
III.
Women who cannot breastfeed or choose not to
Current prevalence of breastfeeding
Trends in industrialized countries
Trends in developing countries
Information and promotion
Weaning
IV.
Infant mortality
V.
Industrialized countries
Developing countries
Measures for reducing infant mortality
Number of infant deaths
Action by the international community
VI.
WHO and UNICEF actions
Meeting on Infant and Young Child Feeding, October 1979
Substance of the Code
UNICEF co-operation in programmes to support brestfeeding and
good weaning practices
Africa
Americas
Asia
Eastern Mediterranean
Advocacy/information
VII. Proposed future programme
Surveillance of breastfeeding trends
Orientation and training of health professionals and other
health workers
Orientation of teachers and extension workers
Informational material for mothers
Health service practices
Nutrition
Professional health non-governmental organizations and
other non-governmental organizations
Information media
Social support systems
Code of marketing of breasmilk substitutes
Board action

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SUMMARY
"Poor infant feeding practices and their consequences are one of the world's major problems,
and a severe obstacle to social and economic development."1 "Breastfeeding is an integral part
of the reproductive process, the natural and ideal way of feeding the infant, and a unique
biological and emotional basis for child development.”2
WHO recommends that breastfeeding should be continued if possible up to the age of 12 months,
or longer in some circumstances to provide a valuable nutritional supplement.34
. "Food comple­
mentary to breastmilk will need to be introduced by 4-6 months; when the nutrition of the mother
is poor...it may often need to be introduced earlier."1
There has been remarkable progress in the technology of making infant formulas. Nevertheless,
scientific evidence is reconfirming the superiority of breastfeeding because of its support of the
bonding of mother and child and the psychological support of the child, the nutritional and
physiological properties of human milk, its immunological properties and other health benefits
extending into adult life, and its advantages for the mother.
Beginning earlier, but mainly in the twentieth century and especially since 1920, breastfeeding
has been declining in urban industrial areas. There has been a decline in the proportion of
mothers who start breastfeeding, and a shortening of the duration to less than three months
("premature weaning"). These trends are now being reversed in upper-income groups in many
industrialized countries. In the rural areas of many developing countries, breastfeeding is
maintained by a high proportion of mothers for 12 months or longer; in others it is falling. The
fall off in low-income urban and peri-urban areas is very significant because of the immigration
of rural population to these areas.
It is important for the health, development and even survival of infants that breastfeeding should
be protected and encouraged, and weaning foods given at the appropriate age. The raising of
the standing of women in their family and community, and the improvement of the nutrition of
pregnant women and nursing mothers, are two of the most powerful ways to support mothers
who want to nurse their babies. Good weaning practices can be encouraged by more
information, help with home and local processing of weaning foods, and social welfare systems
to supply foodstuffs to low-income families where required.
Infant mortality has declined to an average level of 13 per 1,000 live births in industrialized
countries, but it is still at 120 per 1.000 live births in developing countries (excluding China),
where there are 1 1 million infant deaths every year, Deaths during the period of weaning in
developing countries are at a level 15 times higher than in industrialized countries. Infant
mortality depends on many factors, and the available estimates cannot be directly related to
breastfeeding and weaning. Nevertheless, experience shows that better infant feeding practices
can make an important contribution to reducing infant mortality.
Child health problems related to infant and young child feeding practices have been a concern
to the governing bodies of WHO and UNICEF throughout the 1970s. This concern resulted in
the calling of the joint WHO/UNICEF Meeting on Infant and Young Child Feeding which took
place in Geneva, in October, 1979. It set our recommendations for the protection of breast­
feeding and the adoption of appropriate weaning practices, including the drafting of a code of
marketing for breastmilk substitutes.
Important beginnings have been made in a number of countries, often with UNICEF co-operation,
in support of breastfeeding and good weaning. They need to be widely extended.
As a follow up to the October 1979 meeting WHO and UNICEF have been working together on
a joint programme of increased support to the practice of breastfeeding and the improvement of
weaning practices, including the following main items:
- orientation of health professionals and other health workers;
- orientation of the education system and other extension services in contact with mothers and
families;
- making information available to mothers through the health services, women's organizations
and the media;
- improvement of health service practices at time of delivery;
- nutrition of pregnant women and nursing mothers, and infants and young children, whose diets
need supplementing:
- family, community and social support systems for breastfeeding and good weaning practices; and
- introduction at international and national levels of a code of marketing of breastmilk substitutes.
The Executive Director recommends that the Board endorse the strengthening of UNICEF
co-operation in country programmes in the above fields.
1.
2.
3.
4.

Joint WHOIUNICEF Meeting on Infant and Young Child Feeding, Geneva, WHO, 1979, "Statement", para. 1.
Ibid., para. 7.
M. Cameron and Y. Hofvander, Manual on Feeding Infants and Young Children, Protein-Calorie Advisory
Group, FAO. Rome, Second edition, 1976, p. 23.
Joint WHOIUNICEF Meeting on Infant and Young Child Feeding, op. cit . "Recommendations", p. 15.

3
I.

IMPORTANCE OF BREASTFEEDING

Development of breastmilk substitutes
1. Until the second half of the nineteenth
century, breastfeeding was accepted as the
natural and inevitable way to feed infants; in
fact it has been a prerequisite for the conti­
nuation of the human species. In a small
proportion of cases, the breastfeeding was done
by wet-nurses. From 1850 onwards there was
more use of artificial feeds (animal milks or
cereal paps), often with disastrous results?
2. Chlorination of water was introduced in the
United Statas in the 1880s; in the first decades
of the twentieth century pasteurized milk became
more widely available, and the kitchen ice-box
made storage feasible. The use of home-made
formulas based on cow's milk began to spread,
especially in the 1920s. The introduction of
tinned evaporated milk in the twenties made
home formula preparation easier for many, and
the duration of breastfeeding grew shorter
Commercially prepared formulas came into use
on a large scale in the 1 950s and 1960s.
As a result of considerable research and
development, they came closer to the compo­
sition and digestibility of human milk?
Substantial declines in breastfeeding from the
1940s to the 1960s are documented for
Poland, Sweden, the United Kingdom and the
United States.
3. In so far as they led to the replacement of
inferior breastmilk substitutes, these develop­
ments represented a great technical advance,
and together with bottles and teats that can be
kept clean in a modern kitchen, they saved
many infant lives. Further, it can be safely
assumed that more lives could be saved if
formula was made available through social
measures to families who need it but lack the
income to buy it? However, in recent decades
extensive research has confirmed the general
superiority of breastfeeding for both infants
and mothers. Many of the reasons apply just
as much in industrialized as in developing
countries.

Bonding
4. Breastfeeding supports emotional and
psychological bonding between the mother and
5.

child, and as a result, skin-to-skin contact and
breastfeeding are now recommended during the
first hours of the baby's life. The early close
contact and the physical mother-child inter­
action, which they both enjoy, play an impor­
tant role in the child's physical development
(of mouth and voice) and psychomotor
development. This interaction also provides
for natural adjustment to the infant's dietary
needs. “On demand" feeding rather than
bottle feeding becomes more practical?

Advantages of breastmilk
5. Breastmilk not only provides all the necessary
nutrients for growth during the first four to six
months of life, but carries antibodies which
protect the child from infections while its own
immune system is developing. Minerals such
as iron and calcium are in a readily assimilable
form? Breastmilk is also economical; the cost
of extra food for the mother is substantially
less—usually only about a quarter of.the cost
of infant formula.
Nutritional and physiological properties
of human milk
6. Human milk has classically been compared
with cow's milk because the latter is the most
available of the animal milks, and is the usual
base for infant formula, whether home-prepared
or manufactured. A joint commentary on
breastfeeding by the Nutrition Committee of
the Canadian Paediatric Society and the
Committee on Nutrition of the American
Academy of Paediatics says, “Differences in
the composition of human milk and unmodified
cow's milk for human milk have been known
for many years. Early attempts to substitute
unmodified cow's milk for human milk were
unsatisfactory for feeding infants
Newer
knowledge of nutritional and physiological
needs of infants and advances in technology
have led to the development of newer infant
formulas which provide many of the nutritional
and physiological characteristics of breastmilk.
However, there are still differences between
infant formulas and breastmilk, and we believe
human milk is nutritionally superior to
formulas ..“The statement goes on to discuss
composition and factors affecting digestibility
and absorption with regard to fat and
cholesterol, protein and iron.5
10
9
8
7
6

Joe D. Wray* “Feeding and Survival: Historical and Contemporary Studies of Infant Morbidity and Mortality ,
paper to be published in Advances in International Maternal and Child Health, vol. II, Oxford University Press.
6. S. J Fomon, Infant Nutrition, Second edition, Philadelphia, Saunders, 1974, chapter 1; D.B. and E.F.P.
Jelliffe, Human Milk in the Modern World. Oxford University Press. 1978, chapter 10; and B. Vahlquist.
"Evolution of Breastfeeding in Europe", Envi ronmenta! Child Health. February 1975.
7. On the other hand, there are unnecessary risks in using artificial feeding where breastfeeding could be done,
especially in conditions of poverty, as explained below.
8. A.M. Raimbault, "Breastfeeding; Influence on the Child's Development", Children in the Tropics.
No. 96, 1974.
9. "Background paper prepared by WHO and UNICEF" (FHE,’IC/79 3) for Joint WHO/UNICEF meeting on
Infant and Young Child Feeding, Geneva. 9-12 October 1979. See also L Hambraeue, "Proprietary milk
versus Human Breastmilk in Infant Feeding" in Pediatric Clinics of North America, vol. 24, No. 1,
February 1977.
10. "Breastfeeding". Pediatrics, vol. 62, 1978, pp 591-601.

4
Anti-infective properties

7. Human milk contains living anti-infective
factors which colonize the infant's intestines and
assist in resistance to infantile diarrhoea or
gastro-enteritis, and respiratory and some other
infections. Colostrum, in the first phase of
lactation, is particularly rich in these. They do
not exist in formula which has to be heattreated.10
11
8. As a result, breastfed infants have lower
rates of infection, both digestive and respi­
ratory, than bottle-fed infants, and the episodes
of diarrhoea are of shorter duration and less
grave. This appears to be true not only under
conditions of poor environmental sanitation,
but also in middle-class communities in the
United States.12
Other health benefits

9. There are other benefits as well. Breast­
feeding minimizes early exposure to various
foods that might produce allergies. Breastfeed
infants have a lower incidence of allergic
manifestations such as eczema, rhinitis and
asthma in children and also later in life.
Breastfeeding reduces chances of over-feeding
in early life, which may thus tend to prevent
long-term obesity. Cholesterol in human milk
may help constrain cholesterol buildup later in
life.13

Advantages of breastfeeding to the
mother
10. In addition to the bonding process between
mother and child, breastfeeding has a number
of advantages for the mother, including
promotion of the involution of the uterus, and
loss of extra fat stored during pregnancy, and
the restoration of the figure. Breastfeeding
also extends the average period of contracep­
tion after giving birth. "Breastfeeding is best
for the health of the young baby, but also for
the health of the mother including the physical,
emotional, and psychological aspects of her
health."1* If the mother is malnourished,
these advantages may be more than counter­
balanced by maternal depletion, 1516because
she will continue to feed her baby reasonably
well, at any rate during the first months, but
at the expense of her own body stores
(paras. 19-22).

Paediatricians' and public health recom­
mendations for North America
11. The Nutrition Committee of the Canadian
Paediatric Society and the Committee
on Nutrition of the American Academy of
Paediatrics concluded their review of breast­
feeding with the following summary :

"(a) Full-term newborn infants should be
breast-fed, unless there are specific contra-indi­
cations or when breastfeeding is unsuccessful;
(b) Education about breastfeeding should be
provided in schools for all children, and better
education about breastfeeding and infant
nutrition should be provided in the curriculum
of physicians and nurses. Information about
breastfeeding should also be presented in
public communications media;

(c) Prenatal instruction should include both
theoretical and practical information about
breastfeeding;
(d) Attitudes and practices in prenatal clinics
and in maternity wards should encourage a
climate which favours breastfeeding. The staff
should include nurses and other personnel
who are not only favourably disposed toward
breastfeeding but also knowledgeable and
skilled in the art;
(e) Consultation between maternity services
and agencies committed to breastfeeding
should be strengthened; and

(f) .Studies should be conducted on the
feasibility of breastfeeding infants at day
nurseries adjacent to places of work subsequent
to an appropriate leave of absence following
the birth of an infant."18
12. The American Public Health Association in
a policy statement on infant feeding in the
United States said :
"Since feeding of infants during their first
year is an important determinant of
lifelong growth, development, and health,
education on infant feeding should be
viewed as a current public health concern...
The position (paper) and supporting
documentation should be used by members
of the Association to develop local policies
and programmes to support breastfeeding

11. Human Milk in the Modern World, op. cit., chapter 5.
12. A S Cunningham, "Morbidity in breast-fed and artificially fed infants". Journal of Pediatrics, vol. 90, No. 5'
May 1977; S.R. Larsen and D. R. Homer, "Relation of breast versus bottle feeding to hospitalization for gastro­
enteritis in a middle-class United States population". Journal of Pediatrics, vol. 92, No. 3, March 1978.
On the other hand, F.O. Adebonojo, "Artificial versus breastfeeding: Relation to.infant health in a middle­
class American community", Clinical Pediatrics, vol. 11. 1972, p. 25, found no difference in resistance to
infection,
13. "Background paper prepared by WHO and UNICEF", op. cit., pp. 7-13.
14. Joint WHO]UHICEF meeting on infant and Young Child Feeding, op. cit., p. 22.
15. Human Milk in the Modern World, op. cit. chapter 6.
16. "Breastfeeding", Pedia'rics, op. cit., p. 598.
L

5
and informed infant feeding practices...
Human milk from the healthy mother is the
best known food for nourishing her infant.
To ensure successful production of milk,
education in breastfeeding should be
provided during prenatal care and the
postpartum period. Hospital obstetrical
care procedures should facilitate early
nurturing...17
Situation of poverty and under­
development
13. There are additional reasons why breast­
feeding is superior to artificial feeding in
situations of poverty and underdevelopment.
Breastfeeding gives the young infant the liquid
required and avoids the need to give water
that is often not clean. The cost of formula is
high in relation to average earnings, so it is
often over-diluted, and the infant is underfed.
Usually, there are no satisfactory facilities for
cleaning and sterilizing bottles and teats.
The cost of fuel is generally high either in
money or in time spent gathering sticks. There
is no refrigeration for keeping formula between
feedings, so it should be freshly made on
demand. As a result of the extreme difficulty
of maintaining hygienic conditions, and the
absence of immune agents in the formula,
bottle-fed babies living in poverty conditions
are at a much higher risk of diarrhoeas which,
in turn, contributes substantially to precipitation
of malnutrition. The continuation of diarrhoeas,
respiratory infections and malnutrition leads to
a higher infant death rate.
II. SUPPORTS REQUIRED FOR
BREASTFEEDING

14. One of the obvious ways to protect and
encourage breastfeeding is to make it more
feasible for the mothers who want it. The
breastfeeding mother needs the support of her
family, her community and the society to which
she belongs. The situation regarding two
subjects, the status of women and maternal
nutrition, is described below The section on
policies and programmes takes up additional
items (paras. 91-108).
Social status of women
15. While the mother is pivotal in matters
affecting her child's health, she may not, in
fact, be taking an active part in decisions
affecting it. This depends particularly on her
expectations about determining her own life­
style, the information to which she has access,
and the weight given to her opinions by her
family and community. These factors are
interrelated. Improving her education, her
access to information and her literacy will also
raise her influence; so will opportunities for

earning income, e.g., through women's
associations, co-operatives, etc. Raising the
level of women's education and standing in
the family is one of the most powerful means
for improving the well-being of young children.
This applies with particular force to infant
feeding.

1 6. In feeding her infant the mother will
choose, if she can, what she considers to be
best for her child. The mother needs
information on breastfeeding and on the
interaction of nutrition, child diseases and child
development. She and her family also need
an understanding of the extra food required
for her during pregnancy and lactation, of
anaemia and of the risk of maternal depletion
(paras. 19-22). In many instances, she does
not have access to such information. Her
instruction may come from her own mother,
relatives, friends, or health workers. Where
family and other support systems are not close
by and the health services are either not
available or unsympathetic, the possibilities
for choosing breastfeeding are lessened
considerably. For the disadvantaged, who may
already feel inadequate, the chances of
receiving positive information and instructions
are even less.
17. Conflicting messages may come into play
that may make it difficult for women to make
the decision to breastfeed. For example, the
traditionalist view in favour as opposed to the
modernist who sees breastfeeding as limiting
women to a nurturing role; erotic images of
the breast depicted in the media as against its
natural feeding function; and advertisements
emphasizing the convenience of infant formula
feeding as compared with feeding on demand.

18. For women to breastfeed, protection and
support is needed at all levels. The objectives
of UNICEF co-operation in programmes
affecting expectant and young mothers is to
assist them to become more self-reliant in the
knowledge needed to make informed decisions,
and in their opportunities for arriving at
decisions that will provide the best childrearing possible under the circumstances.18
Maternal nutrition
19. At the beginning stage of her pregnancy
a woman weighing 50 kilogrammes (a weight
typical of many women in developing
countries), needs 2,000 kilocalories per day
with moderate activity. During the second
half of pregnancy the need for calories is
increased by 16 per cent and that of protein by
30 per cent. During the first six monts of
lactation the need for calories is increased by

17. "Infant Feeding in the United States", American Journal of Public Health, vol. 71, No. 2, February 1981,
p. 207.
18. Joint WHOIUNICEF meeting on Infant and Young Child Feeding, op. cit. pp. 21 -22. covers part of the above.

6
25 per cent and that of protein by 50 per cent,
and vitamin A by 70 per cent. Also, there is
an additional need for iron among women
whose stores have been depleted.10 An
increase in the daily diet of, for instance,
cereals, of about 200 grammes of cereal plus
vitamins.and minerals, would be needed to
provide the additional needs for calories and
other nutrients during late pregnancy and
lactation
20. Under conditions of poverty, a dietary
supplement even if available is often not
eaten but shared with other members of the
family. Women arrive at conception with
depleted nutrient stores resulting from
generations of poor nutrition, inadequate food
intake, and the drain of infection, parasites,
physical labour or closely spaced pregnancies.
Weight gains during pregnancy are much
below those in well-nourished women, anaemia
from iron and folate deficiency is common,
maternal mortality rates are high, and babies
of lower birth weight are prduced who have a
higher risk of perinatal morbidity and mortality.
Although the foetus receives considerable
protection at the expense of the mother, she
is less able than a well-nourished mother to
pass on nutrients for foetal needs, nor is she
able to build up her own reserves to ensure
prolonged and successful lactation. Many
mothers may go on to their next pregnancy
without an opportunity to achieve full
nutritional recovery.

21. Improved maternal nutrition merits special
attention for three major health objectives :
- Preservation and improvement of the health
status of the mother so that she can be
healthy, economically productive and socially
active;
- Improved birth weight, which gives the
newborn a better start for survival and
healthy growth; and
- Provision of breastmilk for the infant in the
first 4-6 months. The basic elements in a
broad approach to maternal nutrition are
skills for healthy living, improved diet,
improved spacing in pregnancy and health
care during pre-natal and post-natal periods.
22. Undernourished women who take dietary
food supplements show increased maternal
weight gain, a small improvement in the baby’s
birth weight and reduced morbidity and

mortality in their infants.19
20 There is also
substantial positive experience with vitamin
and mineral supplementation during pregnancy.
Policies and programmes addressed to these
needs are listed in section VII.

III.

CURRENT SITUATION AND RECENT
TRENDS

Women who cannot breastfeed or
choose not to

23 In regions where breastfeeding is taken
for granted as the natural way to feed infants
in normal circumstances, nearly all infants are
breastfed by their mothers. Only the death
or illness of the mother prevents it. In
traditional societies, fewer than 1 per cent of
mothers are unable to breastfeed.21 Thus the
strictly "physical" constraints on breastfeeding
are not extensive, unlike family, psychological
and cultural constraints.

24. Successful breastfeeding requires psy­
chological confidence on the part of the
mother—she should not doubt her ability
to breastfeed, nor worry about whether she is
adequate, or whether substitutes would be
better. It is probably an advantage to have
seen breastfeeding by her own mother, or in
her own surroundings. She needs the support
of her family, of health workers who are in
contact with her, and of the surrounding
community and society. "Given adequate
instruction, emotional support, and favourable
circumtances, 96 per cent of new mothers can
breastfeed successfully."22
25. In many "modern" communities these
psychological underpinnings are no longer
present. In such communities there is a
significant percentage of mothers who want
to breastfeed, but are incapable of doing so.
Similarly, the period after which the mother's
milk supply begins to decline, leading her to stop
breastfeeding because of "insufficient milk",
is largely culturally determined.23 Presumably
this confidence can be rebuilt, perhaps in the
next generation. "With adequate teaching and
support, almost all mothers are capable of
breastfeeding and solving any problems which
may arise: The best teachers will be breast­
feeding mothers."24
26. A further group of mothers does not
breastfeed because the physical support systems

19. Manual on Feeding Infants op. cit., table 2.
20. "Report of the Third Metting of the Administrative Committee on Co-ordination/Sub-Committee on Nutrition,
Consultative Group on Maternal and Young Child Nutrition". Food and Nutrition Bulletin, United Nations
University, vol. 3, No. 1, January 1981.
21. "WHO Collaborative Study on Breastfeeding", MCH/79.3. table 2.1, p. 15. The number of rural mothers
breastfeeding in Ethiopia, India, Nigeria and Zaire was recorded as 100 per cent at nine months.
22. Nutrition Committee of the Canadian Pediatric Society and Committee on Nutrition of the American Academy
of Pediatrics, "Encouraging Breastfeeding", Pediatrics, vol. 65, No. 3, March 1980.
23. "WHO Collaborative Study on Breastfeeding", op. cit., p. 14.
24. Joint WHOIUNICEF Meeting on Infant and Young Child Feeding, op cit.. p. 10.

7

are lacking in the family or in society, e.g.,
they have to go out to work in circumstances
where breastfeeding is not possible.
27. A further group may decide not to breast­
feed for other reasons, including their own
choice.

(b) At the other end of the socio-economic
scale, rural populations in many developing
countries maintain a high proportion of
breastfeeding until the baby is 12 months old,
such as 99 per cent in India; 98 per cent in
Ethiopia; 97 per cent in Nigeria; and 96 per
cent in Zaire. However, in some countries
there has been a substantial fall-off also in
rural areas, to levels such as 40 per cent in
Chile, and 63 percent in the Philippines.

Current prevalence of breastfeeding
28. In most industrialized countries, a high
proportion of mothers begin to breastfeed but
(c) The urban poor are in an intermediate
stop quite soon, a phenomenon described as
position between the economically advantaged
"premature weaning". In most developing
and rural areas, with Ethiopia, India, Nigeria
countries, there is a big difference between the
and Zaire showing a high level at 3-4 months,
prevalence of breastfeeding in urban and rural
which is also well-maintained to 6-7 months;
areas. "Partial breastfeeding" is a further
but Chile, Guatemala and the Philippines
complication, e.g., the mother may be away
showing a substantial fall-of :
from her baby at work and obliged to arrange
for artificial feeds (unfortunately, the reduced
Per cent of mothers breastfeeding
infant sucking often leads to an insufficient
milk supply and the early termination of
at 3-4 months at 6-7 months
breastfeeding). Thus, it is difficult to describe
Chile
80
40
the present situation through the use of a
single measure. Somewhat arbitrarily the
Guatemala
76
73
following paragraphs use approximately four
Philippines
61
53
months as a convenient age at which to
measure the prevalence of breastfeeding,
Because of increasing migration from the
where there is a choice of date. Though it is
country into peri-urban areas, this group is
recommended to maintain breastfeeding for
particularly indicative of current trends,27
1 2 months or even longer if possible, the most
important period is the first four to six months.2526
Trends in industrialized countries
After that age it is in any case, necessary to
30. In industrialized countries, beginning early
begin to introduce complementary weaning
in the twentieth century, breastfeeding patterns
foods.
showed a downward trend but it is now being
reversed. In the United States and Western
29. During 1975-1978, WHO organized a
Europe, there was a dramatic decline beginning
study of breastfeeding by collaborating centres
in the 1930s and continuing through the
in nine countries and covering 23,000
1 960s. For example, in the United States in
mothers.25 The prevalence varies widely,
1920, two out of three mothers breastfed their
suggesting that the situation is evolving, and
first child, but between 1936 and 1940 only
is at different stages of evolution in different
one in three mothers did so
By 1972 only
countries. However, there is a considerable
28 per cent of infants born in the United States
uniformity of pattern within socio-economic
were being breastfed at one week; 15 per cent
groups:
by two months, and 5 per cent by six months.28*
(a) Among the economically advantaged,
breastfeeding usually falls off rapidly with the
age of the baby. While at 1-2 months, 61
per cent of infants are being breastfed in the
Philippines; at 3-4 months the figure is 27
per cent. The comparable figures for
Guatemala are 44 per cent and 29 per cent;
for Chile the figures are 80 per cent and 56
per cent There are also countries where this
fall-off has not occurred at the age of 3-4
months, e.g., 100 per cent in Zaire; 96 per cent
in Nigeria; 84 per cent in India;

31. Similarly, in Sweden, official statistics
show that in 1944 about 85 per cent of the
mothers were breastfeeding their infants at
two months, and 55 per cent at six months.
By 1970, 35 per cent were breastfeeding at
two months, under 5 per cent at six months.18
In England; it was estimated in 1969 that
only 33 per cent of the mothers fully breastfed
beyond the first four weeks, and in France an
investigation of national scope in 1972 found
that 36 per cent of the mothers were breast­

25. ' Background paper prepared by WHO and UNICEF", op. cit.. p. 22.
26. • WHO Collaborative Study on Breastfeeding", op cit. The nine countries were Chile, Ethiopia, Guatemala.
Hungary, India. Nigeria, the Philippines, Sweden, and Zaire.
27. Ibid, table 2. 1.
28. Infant Nutrition, op. cit.. chapter 7; H.F. Meyer, "Breastfeeding in the United States", Ciinica! Pediatrics.
December 1968, pp. 708-715.
29 S. Sjolin, Semper Nutrition Symposium. Stockholm, 1973.

8
feeding their child on the fifth day.30

32. In the last decade there has been a reversal
of these trends in both Europe and North
America. In Sweden, for example, a WHO
study in 1976 showed that 93 per cent of the
mothers in the sample initiated breastfeeding
after delivery, and at four months almost 50
per cent of them were still breastfeeding,
although with regular food supplements.31
Other reports of substantial increases in
breastfeeding have come from Australia,
Denmark, France, Japan, Norway and the
United Stales. The report of the French
study concluded with an interesting obser­
vation, that among French women, breast­
feeding is not viewed as a survival of the past;
on the contrary, it is associated with modern
techniques (use of contraception and health
checkups during pregnancy).32

to 50 per cent,34 which seemed still to be the
proportion in the collaborative study. Declines
have also been documented in Brazil, Chile,
Mexico, and Thailand.35

Information and Promotion

35. In 1910, Dr. I.E. Holt in an article "Infant
and mortality and its reduction, especially in
New York City"3637 said “Little or nothing has
been done systematically in this country to
encourage maternal nursing... In New York
we have been so much engaged in the
furtherance of the best methods of artificial
feeding that means of promoting maternal
nursing have not received due consideration.
We must be on our guard lest with our day
nurseries and milk depots and other means we
do not encourage artificial feeding and
discourage maternal nursing./ In 1910, 85
per cent of mothers were reported to be
breastfeeding for at least three months.

Trends in developing countries

33. The situation in developing countries has
been studied less than that in industrialized
countries, and the information reported does
not go as far back
The situation revealed at
the moment of the WHO collaborative study
seems to:be a “still photo" of a process of
decline in breastfeeding. As mentioned above
in paragraph 28, breastfeeding among urban
economically advantaged families falls off
rapidly with the age of the child. Unlike the
situation in industrialized countries, women
with more education were breastfeeding less.
Among urban low-income families breatfeeding
also falls off in many countries, though less
rapidly. In rural areas in many countries
breastfeeding is well maintained until 12
months or longer. This seems to confirm
what commonsense suggests, that trends
spread from the economically advantaged to
the new migrants into urban areas, and then
back to the rural areas with which they
maintain some contact. Furthermore, countries
whose “modernization" has been going on
longer, e.g., the Philippines, Guatemala, and
Chile have a generally lower breastfeeding rate
in rural areas than say Nigeria and Zaire.33
In the Phillippines in 1955, 90 percent of
babies born in low-income areas of Manila
were still being breastfed at 1 2 months post­
partum, but by 1964 the proportion had fallen

36. Diversion from breastfeeding through
practices in medicine and health services is a
matter of concern to this day. In recent
decades the problem has been accentuated by
the promotion of commercial breastmilk
substitutes through advertising to the public
and through medical and health personnel and
health service systems. There is fairly general
agreement, including in codes that have been
adopted by some of the infant formula
companies that such promotion e.g., through
the use of milk nurses, direct promotion to the
mother, etc., must be controlled.
37. The WHO collaborative study noted that
in some developing countries where the
prevalence and duration of breastfeeding was
low, there was also intense marketing and
sales of breastmilk substitutes. In some
countries information about commercial
products was sometimes provided within and
through the health services, be it through
printed material, direct contact with represen­
tatives of commercial concerns or through
free-sample distribution.3’

38. On one occasion. Dr. G.J. Ebrahim,
Institute of Child Health, London University,
received letters from some 50 concerned
paediatricians working in 13 developing

30. “Background paper prepared by WHO and UNICEF", October 1979, PHE/ICF/ 79 3, pp 19-20; Y. Hofvander
and S Sjolin, "Breastfeeding, trends and recent information activities in Sweden", Department of Paediatrics,
University of Uppsala (Sweden) 1979.
31. Ibid
32. C. Rumeau-Romquette and M. Deniel, "L' allaitement maternel au cours de la periode neonatale". Archives
Francaises de la Pediatrie, 1977, vol. 34, pp. 771-780.
33. "WHO Collaborative Study on Breastfeeding", op. cit., table 2. 1.
34. Background paper prepared by WHO and UNICEF, op. cit., p. 20.
35. Human Milk in the Modern World, op. cit., chapter 11; J. Knodel and N. Debavalya "Breastfeeding in
Thailand: Trends and Differences, 1969—1979", Studies in Family Planning, vol. XI, No. 12 (1980).
36. Jouma! of the American Medical Association, vol. 54, 1910, pp. 682-690.
37. "Background paper prepared by WHO and UNICEF", op. cit., p. 22.

9
countries describing promotional practices
they had observed.38
39. Measurement of effects of specific
promotion is known to be difficult. Never­
theless, certain approaches are commonly used
because of a general acceptance that they
have some significant effect. Hence adver­
tising to the public in the media and promotion
at point of retail sale are assumed to be
effective inducements. Since it is impossible
to direct such promotion only to those who
have decided not to breastfeed, otherwise
acceptable messages can have harmful side
effects
A flow of controversial statements
and demands through the media and
advertising interact with other aspects of
changes through urbanization to disrupt the
sense of security that is needed for successful
breastfeeding.3940 Professor Sjolin, University
Hospital, Uppsala, Sweden, in a recent letter
Lancet (7 March 1980), said that normal
marketing methods should not be used for
breastmilk substitutes.

40. T.H. Greiner, in a study in St. Vincent,
found that infant food brand-name recall by
the mother was associated with earlier
supplementation with commercial infant foods
and earlier weaning 10
41. Recent studies of a low-income population
by the Institute of Preventive Medicine of the
Paulista School of Medicine have shown the
permeation of promotion of milk powder and
formula through medical and health personnel
to the mothers at maternity clinics. Only 6
per cent of mothers received information on
breastfeeding but most were informed about
formula feeding. The majority of the doctors
interviewed (82 per cent) believed that the free
distribution of breastmilk substitutes had great
influence on the decline of breastfeeding.41

IV.

WEANING

42. Weaning 42 is the second main aspect of
infant and young child nutrition, and in
conditions of ignorance or poverty presents
serious problems of child health and deve­

lopment.43 Normally, breastfed children grow
at the same rate all over the world up to the
age of four to six months, when the mother's
milk is no longer sufficient and complementary
semi-solid or solid foods should be introduced.
Typically, in low-income areas the infant’s
growth begins to falter at this age, i.e., it falls
behind the reference pattern of the well-fed.44
While mortality is highest during the first year
of life, the proportion of malnourished children
(among survivors) is highest during the second
and third year of life, and typically reaches a
peak at about 24 months. In rural areas where
breastfeeding is almost universal, the current
pressing nutritional problems are to protect
breastfeeding and to ensure the timely
introduction of complementary foods, and
prevent and treat diarrhoeal diseases. It is a
problem of information as well as poverty,
because the requirements of the infant are
small in relation to family food consumption.
43. In addition to the risk of an insufficiency
of complementary food, the change-over from
sterile breastmilk with its anti-infective factors
to animal milk, semi-solid and solid foods
which often have to be acquired, stored and
fed in unsanitary fashion brings the highest rate
of infection, particularly of the gastro­
intestinal tract, that the child encounters in an
entire lifetime.45* The young child mortality
rate (between one and four years), though
much lower than for infants, is typically 15 per
1,000 for each year, some 15 times the rate
found in industrialized countries.44 Thus the
average of 30 deaths per thousand during the
two-year weaning period (taken as the second
and third year of life) amounts to one quarter
of the average 120 deaths per 1,000 during
infancy.

44. "Foods that are locally available in the
home can be made suitable for weaning, and
their use should be strongly emphasized in
health, education and agricultural extension
programmes. Foods traditionally given to
infants and young children in some populations
are often deficient in nutritional value and
hygiene, and need to be improved in various

38. The Lancet. November 27 1976, p. 1194.
39. Stig Sjolin, Semper Nutrition Symposium. Stockholm, 1973. See also Human Milk in the Modern World.
op. cit.. pp. 225-233
40. T H. Greiner, "Infant Food Advertising and Malnutrition in St. Vincent", Cornell University, Ithaca
(New York), 1977.
41. Research project on the impact of dietary habits on the nutritional condition of nursing infants and
pre-school children, April, 1980.
42. "Weaning" as used in this paper means the transition from mother’s milk or formula to regular family food,
and usually extends over 18-30 months (the "weaning period"). It is not used to denote the moment at
which nursing stops.
43. N.S. Scrimshaw aud B.A. Uuderwood, "Timely and appropriate complementary feeding of the breastfed
infant - an overview:’. Food and Nutrition Bulletin, United Nations University, vol. 2, No. 2. April 1980. p. 21.
44. As recorded for example in the guidelines on "growth charts:’ (A growth chart for international use in
maternal and child health care. WHO. 1978).
45. Mannal on Infant Feediug. op. cit.. chapter 3.
46 World Development Report. 1980. World Bank, table 21. average of low-income and middle-income countries

10
ways. Mothers need guidance to improve
these traditional foods through combinations
with other foods available io them locally.
Countries should determine the need for
subsidizing weaning foods or otherwise
helping to ensure their availability to lowincome graups."47 Section VII refers to action
about these points.
45. The use of complementary or weaning
foods may need to be continued to the age of
between one-and-a-half to two-and-a-half
years, by which time a transition to the house­
hold diet can be completed. The nature of the
household diet affects the age at which the
weaning process can be finished, according to
its bulk, its lack of protein, the presence of
strong spices, etc.
46. Industrially produced weaning fonds are a
convenience; usually the lower-income families
cannot afford them. UNICEF for many years
was co-operating in country programmes to
produce lower-priced milk products or weaning
foods: however, in low-income countries these
could not be made available to the low-income
population through subsidy on a sufficient
scale. Hence, UNICEF is now focusing its
co-operation on programmes for the preparation
of local foods in the household or in the
community.

V. INFANT MORTALITY
47. It has been pointed out above that
breastfeeding avoids sources of infection;
conveys protection against infection; and
produces a better nourished and more resistant
infant, especially in families who cannot afford
the necessary quantities of breastmilk substitutes
(paras. 5-10). Poor infant feeding practices
lead to illness on a large scale, and death on
a much smaller scale. Usually it is only the
latter that is recorded in the statistics.
48. There is no simple connection between
estimates of infant mortality rates for a country
and bottle feeding; infant mortality results
from far too many other factors as well.
Infant mortality 4849appears to have been
declining during the nineteenth and twentieth
centuries in the now industrialized countries,
and during the twentieth century in the
developing countries. The decline began long
before the introduction of bottle feeding
and has continued during the bottle-feeding
period. Rural areas of countries where
traditional ways of life continue and where

breastfeeding is high, also have high infant
mortality (e g , Nigeria, Zaire). The reasons
include lack of education and information
among mothers, poor maternal nutrition, lack
of knowledge and resources for weaning foods,
and lack of health services. There is sufficient
evidence to show that under conditions of
rural poverty, risk of infant death would be
even higher in the absence of breastfeeding.
In other words, breastfeeding has a very
important role in preservation of infants' lives
and prevention of further deterioration in
areas of high infant mortality.

49. The important fact is that in developing
countries infant mortality remains alarmingly
high, on the average 10 times the level of
industrialized countries. Hence the search for
all available measures to reduce it, to which
the improvement of infant feeding and weaning
can make a signiticant contribution.

Industrialized countries
50. The earliest records are for death rates of
the population as a whole, rather than infant
mortality. However, wherever the death rate
is high, infant mortality accounts for a sub­
stantial part. Hence, it is significant that in
modern times, records show a declining death
rate beginning first in Sweden in the eighteenth
century, and in the nineteenth century
beginning in France and England.40 There are
also Swedish records of infant mortality, with
a decline beginning in the mid-eighteenth
century.50 In the 1870's infant mortality was
still nealy 300 per 1,000 live births in southern
Germany, but had fallen to 100 in Norway.
The decline in most industrialized countries
was particularly rapid in the first half of the
twentieth century, and is now down to 1 3 per
1,000 live births.51 The decline in mortality
was followed some decades later by a decline
in the birth rate, thus completing the demo­
graphic transition from high birth rates and
high death rates to low birth rates and low
death rates. In industrialized countries, where
immunization, drugs and health services are
available, the loss of the protection afforded
by breastfeeding appears to result in higher
morbidity rather than higher mortality.

Developing countries

51. Infant mortality rates for developing
countries are usually based on a nation-wide
sample of the population, and under that
system it is not possible to make a reliable

47. Joint WHOIUNICEF meeting, op. cit.. p. 15. See also "Report of the Third Meeting of the ACC/SCN
Consultative Group on Maternal and Young Child Nutrition", Food and Nutrition Bulletin, United Nations
University, vol. 3, No. 1., Jauuary 1981.
48. Infant mortality is defined as occurring during the first 12 months of life, and is recorded as number of deaths
per 1,000 children born during the same year.
49. Thomas McKeown, The Modern Rise of Population. New York, Academic Press, 1976. p. 28.
50. B. Vahlquist, cited in Human Milk in the Modern World, op. cit.. chaptar 10.
51. World Development Report, 1980. World Bank, table 21 for high income industrialized countries.

11
breakdown into economically advanced areas,
poor urban areas, and rural areas (as used
above in para. 29), however, it is generally
believed to be much higher in the last two
areas 52 and one of the objectives of primary
health care is to improve their situation. The
protection and promotion of breastfeeding and
better weaning practices is part of the primary
health care strategy.
52. At the beginning of this century, infant
mortality in the country as a whole was often
200 to 300 per 1,000 live births, as it had
been 100 and 150 years ago in the countries
that are now industrialized. There have been
striking declines in recent decades, particularly
from the 1 930s to the 1 960s.5354The rate is
now down to a global average of 120 for
developing countries (excluding China) —
approximately 1 0 times the rate of the
industrialized countries. The target for the
year 2000 included in the International
Development Strategy of the Third Develop­
ment Decade is to bring the rate down to 50,
still four times the level of industrialized
countries.51

Measures for reducing infant mortality
53. The reduction of infant mortality calls for
many measures in an economic, social and
cultural complex. They include clean water,
better hygiene, better environmental sanitation,
immunization and access to health services;
better feeding practices; and above all, the
education and status of women, which affect
the preceding factors.5556

54. Since poor infant feeding practices result
not only in illness, but also in death, improve­
ment in mortality rates could come about
particularly by reducing the deaths due to
diarrhoeas, infections and weakened resistance
caused by . uor nutrition. "Evidence from the
developing countries indicates that infants
breastfed for less than six months, or not at
all, have a morality rate five to ten times higher
in the second six months of life than those
breastfed for six months or more "55
Number of infant deaths
55. Approximately 12 million infants die every

year, 11 million of them in developing
countries. If the rate of infant mortality is
brought down to the target level of 50 per
1,000, this will mean saving approximately 6
million infant lives. At high rates of infant
mortality, one third or approximately 4 million
of the infant deaths occur in the neonatal
period (0-28 days of age).57 These are due
to low birth weight, tetanus and other
infections, accidents and miscellaneous causes.
Better maternal nutrition could reduce the
number of infants born with low birth weight
(para. 21). The other two thirds of infant
deaths (from 28 days to one year of age),
amounting to approximately 7 million, are
caused inter alia by malnutrition, gastro­
intestinal, respiratory and other communicable
diseases, and could be substantially reduced
by better feeding practices, especially pro­
tecting and promoting breastfeeding and the
timely introduction of weaning foods.

VI.

ACTION BY THE INTERNATIONAL
COMMUNITY

56. Confirmation on the part of the medical
and scientific communities of the importance
of breastfeeding led the international
community to give more attention to the
question of appropriate infant and young child
feeding. During the 1960s the Protein
Advisory Group (PAG) of the United Nations
system 5859
encouraged studies in infant feeding
and in 1969 established an ad hoc working
group on feeding the pre-school child. In
1971, the Group published its report, "Feeding
the Pre-School Child", 53 which in section 4
treated the "sociocultural dynamics for
breastfeeding" and drew attention to a
dangerous decline. The Group also organized
the preparation and publication of a manual
for professional field-workers on feeding
infants and young children, which has been
translated into many languages and has
become a standard text used by health services
and voluntary organizations. It has been
frequently cited above.60
57. At the same time the advertising of infant
formula and free distribution of samples by
the infant food industry became a matter of

52. In Thailand, see J. Knodel and A. Chamratrithirong, " Infant and Child Mortality in Thailand: Levels,
Trends and Differentials as derived through indirect estimation techniques". Papers of the East-West
Population Institute, No. 57, 1978.
53. The Determinants and Consequences of Population Trends. United Nations, 1973, vol. I. chapter V. paras.58-7O.
54. General Assembly resolution 35/56, para. 48.
55. Thomas McKeown, The Modern Rise of Population, op. cit., p. 28. Walsh McDermott analysed New York
city's decline in infant mortality during the period 1900 to 1930, "Modern Medicine and the demographic
disease pattern of overly—traditional societies: A technological misfit". Journal of Medica\ Education.
vol. 41 (supplement) 1966.
56. "Maternal and Child Health:’, report by the Director-General, WHO. (A/32/9), 1979, para. 45.
57. Determinants and Consequences of Population Trends, op. cit.. para. 69.
58. The Protein Advisory Group, later renamed Protein-Calorie Advisory Group, consisted of experts in fields
related to nutrition aud advisad agencies in the United Nations system.
59. Protein-Ca.orie Advisory Group document 1 14/5.
60. Manual on Feeding Infants and Young Children, op. cit.

12
concern. In November 1970, in Bogota,
Colombia, the Pan American Health Organi­
zation (PAHO) and UNICEF sponsored an
international meeting of paediatricians,
nutritionists, and representatives of the infant­
food industry to discuss the problem. As an
immediate result of the meeting, at least one
of the larger companies changed some
marketing practices.

considered a report on "Priorities in child
nutrition in developing countries", prepared
under the direction of Dr. Jean Mayer, then
Professor of Nutrition, Harvard University
School of Public Health. One of the recom­
mendations was that "UNICEF should continue
to support efforts to protect and promote the
practice of breastfeeding infants".63 The
Board conclusions included the following :

WHO AND UNICEF actions

"Particular emphasis was given to the effort to
arrest the decline of breastfeeding. Among
the many measures that might be advisable
was the control of advertising of infant and
weaning foods, for which it might be useful
to prepare model legislation and adopt social
measures for nursing mothers when they
worked outside their homes."64

58. During the early 1970s, the UNICEF
Executive Board took note of concern over the
decline of breastfeeding on a number of
occasions. The report of the Lome Conference61
noted that most of the country studies revealed
a lack of knowledge of proper weaning
procedures and that this was leading to an
abrupt or premature ending of breastfeeding
without the gradual introduction of transition
foods. As a result, increased co-operation
was recommended for nutrition education for
pregnant women and lactating mothers and
the production of weaning foods locally
produced.

59. A report on policy and programmes
concerning the young child 62 considered by
the UNICEF Board at its 1974 session,
suggested a number of actions to encourage
breastfeeding, including the study of reasons
for its decline; orientation and training of
medical and health personnel; public education;
ano support for nursing mothers. The Board
agreed that UNICEF should increase its
assistance in these areas. Support was also
approved for the Protein-Calorie Advisory
Group to promote, along with its other spon­
soring agencies, co-operative action by
paediatricians, government agencies and the
infant-food industry in minimizing
problems in early weaning.
60. In 1974, the World Health Assembly
passed a resolution recommending the
encouragement of breastfeeding as the ideal
feeding in order to promote harmonious
physical and mental development of children;
calling for adequate social measures to support
breastfeeding mothers; and urging Member
States to review promotion activities for baby
foods (WHA. 27/43).
61.

In 1975 the UNICEF Executive Board

62. In reviewing UNICEF work in the field
of child nutrition during the Board session of
1 977, several delegations said that consi­
derably increased emphasis was required to
discourage premature weaning from breast­
feeding. The Board was informed that the
WHO collaborative study was under way and
hoped that it could lead to consideration in the
UNICEF/WHO Joint Committee on Health
Policy, and "a more systematic approach by
UNICEF to the problem".65
63. The following year the board was informed
that work had started in several countries with
WHO and UNICEF assistance to identify the
main factors influencing the decline of breast­
feeding and to develop means of countering
these factors.66 The Board expressed its
support of an expansion of UNICEF
co-operation in this area, with WHO.
Meeting on Infant and Young Child
Feeding, October 1979

64. Intersecretariat consultations on the WHO
and UNICEF programme led to a joint decision
to convene a meeting on infant and young
child feeding in October 1979 in Geneva.
With representatives participating from
Governments, international agencies, the health
professions, the infant-food industry and non­
governmental organizations, the meeting
recommended changes in hospital practices;
more support for the encouragement of breast­
feeding through information and guidance
under the health care system; measures to

61. Children. Youth. Women and Development Plans in West and Central Africa, report of the Conference of
Ministers, Lome, Togo, May 1972 (UNICEF, Abidjan).
62. "The Young Child: Approaches to Action in Developing Countries", (E/ICEF/L. 1303).
63. "Priorities in Child Nutrition in Developing Countries, General Recommendations to UNICEF and
Governments", vol, I (E/ICEF/L. 1328).
64. Official Records of the Economic and Social Council, Fifty-ninth session. Supplement No. 6 (E/ICEF/639,
para. 66).
65. Official Records of the Economic and Social Council. Sixty-third session. Supplement No. 12
(E/ICEF/651, para. 120).
66. "General progress report of the Executive Director, Chapter II: Programme progress and trends"
(E'ICEF/654 (Part II), paras. 162-167).

13
ensure that women's nutritional and health
needs were met, especially during pregnancy;
changes in obstetrical procedure and practices
to facilitate breastfeeding; more information to
the health professions during training, and
orientation of other professions in contact with
the public; and stronger support system for
women working while continuing to
breastfeed.07
65. The meeting recommended follow-up
activities by various groups :
(a) Governments have a major responsibility
to work with communities to give the necessary
support to families living below the income
level which would enable them to provide food
for pregnant and nursing women, and infants
and young children. Often social measures
are also required for the support of breast­
feeding, especially for working mothers;
(b) The health services and health professions
have a prime responsibility for the advice given
to women, the organization of maternity and
mother and child health care services, and the
training of professional, auxiliary and
community health workers;

(c) Industry has the responsibility to continue
to make supplies of breastmilk substitutes of
good quality for those who need them, but
promotion to the public should stop;
(d) Women's organizations should play a larger
part in community and national decisions in
this field, including the organization of
information campaigns, support networks for
breastfeeding mothers, and assistance in
monitoring good marketing practices; and
(e) The information media have an important
role for several audiences—families, mothers,
youth and others.

66. The meeting also recommended the
promotion and support of appropriate weaning
practices, with emphasis on the use of locally
available foods.
67. While recognizing that manufactured
infant formulas were excellent products for
infants who were not breastfed—and in fact
needed by many families who cannot afford
them—the meeting stated that promotion to
the public and to mothers should stop There
should be an international code of marketing
of infant formula and other breastmilk
substitutes. This should be supported by both
exporting and importing countries and observed
by all manufacturers. WHO and UNICEF were
requested to organize the process for its

preparation, with the involvement of all
concerned parties.

68. The World Health Assembly in May 1980
endorsed the statement and the recommenda­
tions of the October meeting, and the work
under way for preparation of the international
code. UNICEF's co-operative effort with WHO
was endorsed in discussions of the UNICEF
Board at its 1980 session. Consultations
with concerned Governments, the infant-food
industry and non-governmental organizations
have taken place and a draft code (WHO
document EB67/20) was considered by the
Executive Board of WHO in January 1981>
and recommended to the 34th World Health
Assembly in May 1981 Jor adoption as a
“recommendation" to Governments in the terms
of the WHO constitution (Article 23).
Substance of the Code

69. The most important provisions of the
proposed Code 08 are contained in the
following extracts, which apart from the first
two on aim and scope, are generally taken
from the opening sentences of the various
articles :
“The aim of this Code is to contribute to
the provision of safe and adequate nutrition
for infants, by the protection and
promotion of breastfeeding, and by
ensuring the proper use of breastmilk
substitutes, when these are necessary, on
the basis of adequate information and
through appropriate marketing and
distribution." (Article 1)
“The Code applies to the marketing, and
practices related thereto, of the following
products : breastmilk substitutes, including
infant formula; other milk products, foods
and beverages, including bottle-fed
complementary foods when marketed or
otherwise represented to be suitable, with
or without modification, for use as a partial
or total replacement of breastmilk; feeding
bottles and teats. It also applies to their
quality and availability, and to information
concerning their use." (Article 2)

"Governments should have the responsibility
to ensure that objective and consistent
information is provided on infant and young
child feeding for use by families and those
involved in the field of infant and young child
nutrition..." (Article 4.1)

"There should be no advertising or other form
of promotion to the general public of products
within the scope of this Code." (Article 5.1)

67. Joint WHOjUNiCEF Meeting on infant and Young Child Feeding. Geneva, WHO, 9-12 October 1979.
68. Dta,^^?!na.tj°^al c°de of Marketing of Breastmilk Substitutes, Report by the Director-General. WHO,
(EB67/20), 10 December 1980.

14

"The health authorities in Member States should
take appropriate measures to encourage and
protect breastfeeding and promote the principles
of this Code..." (Article 6.1)
"The use by the health care system of profes­
sional service representatives, mothercraft
nurses or similar personnel, provided or paid
for by manufacturers or distributors, should not
be permitted." (Article 6.4)

"Donations to institutions., of infant formula
.. should only be used or distributed for infants
who have to be fed on breastmilk substitutes."
(Article) 6.6)
"Health workers should encourage and protect
breastfeeding..." (Article 7.1)

"...Health workers should not give samples
of infant formula to pregnant women, mothers
of infants and young children, or members of
their families.' (Article 7.4)

"Labels should be designed to provide the
necessary information about the appropriate
use of the product, and so as not to discourage
breastfeeding.” (Article 9.1)
"The quality of products is an essential
element for the protection of the health of
infants and therefore should be of a high
recognized standard." (Article 10.1)
"Governments should take action to give effect
to the principles and rules of this Code, as
appropriate to their social and legislative
framework, including the adoption of national
legislation, regulations or other suitable
measures..” (Article 11,1)
UNICEF co-operation in programmes
to support breastfeeding and good
weaning practices
70. In all regions, UNICEF co-operates in
some activities and services in support of
breastfeeding and appropriate weaning
practices, some of which are of long standing.
Much wider extension is needed. UNICEF’s
co-operation includes support for :
- Reorientation of training of health personnel,
both pre-service and in-service, in
co-operation with WHO;
- Information programmes for use by women's
organizations and other local support
systems;
- Introduction of mother and child weighing
as a routine in maternal and child health
services;
- Maternal, infant and young child supple­
mentary feeding through community
involvement, especially in primary health
care services;

- Local studies of infant and yong child
feeding practices;
- Extension of day-care facilities, especially
in low-income urban areas; and
- Local weaning food production through
agricultural planning, agricultural extension,
"applied nutrition", home or community
processing of foods, etc.
Some examples are given in the following
paragraphs.
Africa

71. In Kenya the gathering of data on breast­
feeding has been incorporated into the
country's household sample survey system.
A research project is in process on the know­
ledge, attitudes and practices of health workers
with respect to breastfeeding. The medical
curriculum is also being reviewed to remove
gaps or defects wich might lead to faulty
counselling and practice. The Kenya Institute
of Education is co-ordinating the study.
72. Over the past two years UNICEF has been
co-operating in a programme of courses for
women on nutrition education and the
preparation of weaning foods in the United
Republic of Tanzania. Co-operation has also
been extended for a project on the production
of soya beans, a main ingredient of the
weaning food lisha
Americas

73. In Brazil the promotion of breastfeeding
forms part of an overall country plan aimed at
incorporating the needs of children in national
development plans. UNICEF is co-operating
in a mass information and communications
programme providing support for technical
advice. This programme aims at :

- Enabling health centres and other relevant
parts of the public health network to educate
the mother, family members, community
workers, etc.;
- Educating medical and health personnel; and
starting to modify medical curricula;
- Motivating and influencing hospital adminis­
trators, architects, the judiciary system, etc.,
so that efforts are made to set up systems
and attitudes that support and facilitate
breastfeeding in hospitals, work places,
maternity clinics, etc.:
- Influencing maternal attitudes to
breastfeeding; and
- Influencing the infant food industry.
74. The Government is undertaking a
systematic evaluation of the efforts under way,
including major action programmes in Sao
Paulo and Recife where breastfeeding had
declined rapidly over the past decade.

15
75. Special programmes to promote breast­
feeding have been supported in the Caribbean
since the mid-1970s, beginning with surveys
on infant feeding partices in Jamaica;
motivation of professional, voluntary and
extension groups through training sessions;
and panel discussions and promotion via mass
media. Building on this experience, the
Caribbean Food and Nutrition Institute, with
assistance from UNICEF and PAHO. organized
a technical group meeting in 1979 to draft
guidelines to promote successful breastfeeding.
Since then, the Institute, with some assistance
from UNICEF, has produced a breastfeeding
promotion package consisting of a manual,
slides, tapes and posters for the sensitization
of policy makers and health teams.69
76, There is concern about the decline of
breastfeeding throughout Central America.
Following the October 1979 meeting in
Geneva, the Institute for Nutrition in Central
America and Panama, with WHO support,
brought together representatives of the health,
education, social services and planning
ministries of six Central American countries in
Tegucigalpa, Honduras, in March 1980.
Recommendations now form the basis for
national action in each country. A
recommendation for “noting" a subregional
programme is before the current Board session
(E/ICEF/P/L. 2043 (REC)). It requests
assistance for training seminars and workshops;
preparation of educational materials; pilot
activities in mass media promotion; and
monitoring compliance with existing and
forthcoming national codes regulating the
promotion of breastfeeding substitutes.

77. The UNICEF regional office in Santiago
supported a seminar on breastfeeding in 1980.
One project for strengthening services for
children in areas of extreme poverty, in which
UNICEF participates in Chile, covers a number
of fields including the extension of breast­
feeding. It provides for the training of health
personnel who, with the help of an orientation
manual and audio-visual material, are
promoting breastfeeding among mothers using
the health services.

78. In Mexico a rooming-in programme is
being supported by the Sistema Alimentario
Mexicano, a network of government agencies
involved in promoting improved food produc­
tion and consumption habits, with the objective
of encouraging breastfeeding and close mother/
child contact.
Asia
79. Bangladesh. After substantial efforts at
attitudinal change about weaning with rural
women who were reluctant to consider the use

of local ingredients and locally produced
weaning foods because these foods are not
considered important, 8,000 rural women in 20
unions are participating in training on their
preparation and use.

80. In Burma studies undertaken since 1957
have shown a high incidence of protein-calorie
malnutrition, especially in children aged one
to two years (late weaning period). A seminar
on breastfeeding and weaning practices held
in 1979 reviewed approaches to bridge the
wide gap between requirements for calories
and their consumption during weaning, and to
develop an action programme to address the
problems. It was agreed that emphasis should
be put on introducing appropriate
complementary foods from four months
onward. UNICEF is now supporting a study
on successful examples of complementary
foods from different regions of the country.
81. Breastfeeding promotion has been a part
of UNICEF co-operation in Indonesia since the
mid-1970s. Information materials, including a
slide/sound presentation, were developed to
help lay a base for programmes to combat the
decline of breastfeeding in urban areas. An
informal working committee was organized
composed of government officials,
representatives of women's groups, and the
medical profession. Studies to provide data
about infant feeding practices were supported,
and a mass media campaign was developed
and carried out in 11 cities during 1980.
82. In the Philippines, the under-six clinic of
the Baguio General Hospital, known for its
pioneering work to encourage breastfeeding
rooming-in, has been designated a national
centre for training health personnel, focusing
on breastfeeding as the most important way
of reducing infant mortality rates. UNICEF
has provided some equipment and training
stipends to the centre. Support is also being
given for the expansion of the under-six clinic
concept for training trainers, and later
all health personnel including doctors, nurses
and midwives of one region of the country.
83. In February 1981, as a follow-up to the
October 1979 meeting, the Ministry of Health
and Social Affairs of the Republic of Korea
sponsored with UNICEF a seminar on infant
and young child feeding involving some of the
country's leading paediatricians and nutrition
specialists. The seminar focused on the status
and problems in breastfeeding and weaning
practices; approaches to promotion; the
mother's role; and education, training and
information. A task force was established to
carry out recommended actions in the main
subject areas.

69. Guidelines for Developing Strategies to Promote Successful Breastfeeding. Caribbean Food and Nutrition
Institute. PAHO/WHO. 1979.

16

84. Thailand. Much of UNICEF co-operation
in recent years has been directed towards the
training of primary health care volunteers and
the training of trainers at different levels in
applied nutrition, nutrition surveillance,
promotion of breastfeeding, village-level food
processing and community gardening. A
campaign in support of breastfeeding began in
1975 as a part of a basic services project in 16
provinces of north-eastern Thailand. To date,
over 1 million mothers have received basic
health and nutrition information with special
stress on breastfeeding.
Eastern Mediterranean
85. In the Gulf Arab States UNICEF is currently
supporting studies on infant feeding practices.
At a regional workshop on nutrition related
to mother and child health in the Gulf countries
held in Bahrain in April 1980. the participants
concluded that despite the high purchasing
power of most of the population and the
availability of foods on the market, nutritional
problems are prevalent in the society and are
mostly affecting infants and pre-school
children. Available studies indicate the
prevalence of wasting, stunting and anaemia
in this age group, in addition to the high
infant and childhood mortality rates. The
participants formulated several recommen­
dations on the use of mass media in encoura­
ging breastfeeding for the health and nutrition
of the population, particularly the mothers.
86. Breastfeeding remains by far the predo­
minant practice in the Sudan. Commercial
substitutes however are sold. At this stage
there is little information available on the
volume of commercial breastmilk substitutes
imported into the country, their distribution,
or most importantly, the long-term trends in
their use by nursing mothers. A study is
currently being supported to research these
and related questions.
Advocacy/information
87. In many countries, the encouragement
of breastfeeding is a theme of advocacy.
Considerable attention is being given to the
development of core materials that can be
adapted for the use of health workers, mothers
and mothers-to-be, non-governmental
organizations and the public at large. They
include slide/sound presentations (Brazil, Chile,
the Caribbean, Indonesia) , booklets and
manuals (Afghanistan, the Caribbean, the
Republic of Korea), radio messages, posters,
etc.

88. During 1980, 1 4 two-minirte radio
programmes were distributed dealing with
breastfeeding, reasons for encouraging the
practice, and other information about infant
feeding, both in the developing and industria­
lized countries. Each language version

(English and French) was distributed to all
National Committees for UNICEF, field offices
and several radio networks.
89. A working group of WHO and UNICEF
staff has been established on information and
liaison with non-governmental organizations,
with a number of publications and activities
scheduled. They include background kits of
information materials for the media and non­
governmental organizations on the importance
of breastfeeding, the need for its protection
and support, and the contents of the draft
code. Articles have appeared in UNICEF
News and World Health. Other publications
are being encouraged to include articles on
various aspects of the subject.

90. Meetings and workshops in developing
countries with the participation of non­
governmental organizations, particularly
women's and consumer groups, are being
scheduled by several UNICEF country offices
for late 1981. It is anticipated that they will
lead to improved support systems for women
who breastfeed, and more information being
made available through non-governmental
organizations about the benefits of breast­
feeding.
VII. PROPOSED FUTURE PROGRAMME
91. The preceeding sections have shown that
the protection and promotion of breastfeeding
and good weaning practices can make an
important contribution to the well-being and
development of children, with effects lasting
into adulthood. A wide range of national
policies and services are needed. Many of
them were put into operation, mostly on a
pilot scale, during the decade of the 1970s.
The WHO/UNICEF meeting of October 1979
resulted in a more comprehensive outline,
some elements of which have been further
elaborated since. WHO and UNICEF have
been co-operating in many of these
prorgammes at the national level, and their
scale now needs to be substantially increased.

92. The following paragraphs summarize the
relevant fields in which it is proposed that
UNICEF should increase its participation in
country programmes. WHO standards and
guidelines are involved in varying degrees in
all of them. For some, WHO would be the
prime mover and UNICEF would have a
supporting role. In others, UNICEF would
have a larger role, particularly at the country
level.
Surveillance of breastfeeding trends
93. Countries need to be able to follow the
trend of breastfeeding and weaning practices
in urban and rural areas, and at different
income levels. Experience has been gained

17
through the WHO collaborative study, and
WHO has a general methodology under
preparation. It is proposed that the
methodology should be tested in a number of
countries and then diffused through regional
working groups. UNICEF will be invited to
contribute to the costs. Countries would
undertake surveys periodically, for example
every five years, and some will seek UNICEF
participation for this.

Orientation and training of health
professionals and other health workers
94. Advice given to pregnant women by
obstetricians, nurses, auxiliaries, primary
care workers, midwives and other health
workers is an important factor in their decision
whether or not to breastfeed, a decision
usually made before delivery. Breastfeeding
can be made easier by certain preparations.
Professionals and other health workers need to
know how to give advice to mothers and
families, and also how to handle problems that
may arise, e g , breastfeeding during sickness.
These questions have been neglected in
health training curricula in recent decades.
Health administrators also need to be
adequately informed in this field. WHO is
preparing training modules for different levels
of training, and will also prepare core teaching
materials. These will then have to be adapted
to differen countries. Refresher courses and
the production of teaching materials in large
quantities, particularly for lower-level workers,
would be supported by UNICEF.
Orientation of teachers and extension
workers
95. In addition to health workers, school­
teachers and extension agents in contact with
the community should be informed about
breastfeeding and weaning, and be able to
give information and advice consistent with
what the health services are providing.
96. This is particularly important for primary
and secondary schoolteachers and for literacy
teachers. Many girls leaving school will be
entering motherhood within a few years.
Thus, it is impo tant to introduce training
modules into teacher training colleges, and
into the material being prepared for literacy
campaigns. Such material would be mainly
prepared at country level, but some core
matenal is needed. The collaboration of
UNESCO would be sought, along with WHO
with respect to technical content.

97. Agricultural and home economics extension
workers, community development workers and
co-operative advisers are all in a position to
influence the community. Orientation materials
need to be prepared in co-operation with FAO
and WHO. The League of Red Cross Societies
is also ready to help in this. Core materials

would be prepared and then adapted to local
needs, country by country. UNICEF support
would be sought towards the costs.

Informational material for mothers
98. Developing countries will need help with
information material for mothers and families
that can be distributed through their health
facilities during pre-natal and mother and child
health consultations. Core material prepared
with WHO's help will have to be adapted to
individual country needs. Some governments
will seek UNICEF's support for this, and for
reproduction (though UNICEF would not have
the means to help with all the quantities
required)
Health service practices

99. A number of hospital practices at time of
delivery affect the initiation and duration of
breastfeeding. These include the information
given to mothers, the supportive attitude of
the staff, the avoidance of too deep sedation
during childbirth, immediate skin-to-skin
contact and nursing of the newborn, the
avoidance of pre-lacteal and supplementary
bottle feeds during the first days of life, and
avoidance of the distribution of samples of
infant formula.
Nutrition
100 Inadequate nutrition presents a serious
problem for pregnant women, for nursing
mothers and for infants and young children
whose family resources are insufficient to
supply the food they need. Long term
improvements in family and community
capacity for supporting better maternal
nutrition and better weaning foods can be
obtained through more information and
education for women and their families.
Support for family food production and
adequate storage is also important, as is the
lightening of women's work, and community
level action to have community gardens and
community facilities for the storage and
processing of weaning food. UNICEF should
expand its co-operation in these fields.

101. Where there are malnourished infants
and young children other services are also
necessary that can give more rapid results
than those just discussed; they also should be
undertaken in a form which leads to long-term
arrangements and self-reliance. For improved
maternal and young child nutrition, the health
services will need to monitor the health and
nutritional status of the mother and child; to
provide nutritional guidance; to reach needy
women and young children in the community;
and to take additional measures such as
distributing food or food coupons to lowincome families where required. External aid
for children's food is available from the

18
World Food Programme and other sources,
but because of national and internationl
financial, logistical and administrative cons­
traints, it covers the needs of only a small
percentage of the population of developing
countries. Food entitlement and assistance
present both administrative and financial
problems, which are under study in a number
of organizations, including UNICEF. Based
on the outcome the Executive Director may
have further recommendations for the next
session.70

Professional health non-governmental
organizations and other non-governmental
organizations

102. The organizations of obstetricians,
paediatricians, nurses and midwives are in a
position to help substantially in encouraging
their members to provide the information
needed by mothers and families. The corres­
ponding international non-governmental
organizations have consultative status with
both WHO and UNICEF, and mutually useful
co-operation can be developed further.
103. Also other non-governmental organiza­
tions can provide information on the promotion
and protection of breastfeeding, in keeping
with their constituencies. Women's organiza­
tions have a particular role to play (paras.
15-18) in both developing and industrialized
countries, especially with respect to promoting,
and providing support services for nursing
mothers. Some organizations are deeply
involved in these activities; more should be
encouraged to undertake them.
104. UNICEF in its co-operation with
non-governmental organizations both through
its Committee of Non-Governmental
Organizations and with particular organizations
engaged in providing developmental services
at the country level, is-encouraging more
co-ordination of activities in this field and the
undertaking of pilot support projects in poor
urban and rural communities in developing
countries.

the guidance of health workers where they are
available. UNICEF should continue to help
countries in production of substantive material
for use by the media, in co-operation with the
health and other concerned ministries. Slide
and sound projections are required for
meetings, and for places where people gather,
such as markets.
Social support systems
106. Social support systems need
strengthening in a number of fields. The
WHO/UNICEF meeting recommended maternity
leave of at least three months; some countries
now extend this to six. Arrangements for
flexible working hours and facilities for
breastfeeding in work-places are very helpful
in industrialized countries, and at present apply
to only a small precentage of the population
in developing countries. Experience has
shown that bath creches and day-care centres
can be developed in residential areas on a
community basis and within the limits of
community resources. UNICEF has helped
such arrangements as part of its participation
in urban services, and this should be very
much expanded.
Code of marketing of breastmilk
substitutes

107. A number of promotional and marketing
practices of breastmilk substitutes should be
revised. These are now set out in the draft
code which goes before the World Health
Assembly for approval in May 1981. The
Director-General of WHO and the Executive
Director of UNICEF have proposed that this
should be approved as a "recommendation"
rather than a "regulation". The Executive
Board of WHO has endorsed the draft code
and recommended its adoption in that form
(EB67/20 and EB67.R12). Some
countries will be seeking advice and help from
WHO and UNICEF about the preparation of
suitable national measures to give effect to
the code
(The code has since been adopted
by the World Health Assembly as the
International Marketing Code for Breastmilk
Substitutes, vide resolution WHA34/22).

Information media
105. The information media, if motivated,
especially radio but also increasingly television,
would be in a position to provide information
to the many who are not in touch with health
services, and to arouse their interest in seeking

Board action
108. The Executive Director recommends that
the Board endorse UNICEF participation in
the above activities to improve infant and
young child feeding practices.

70. Funds to make some start with this work during the next twelve months are recommended in
E/ICEF/P/L. 2026 (REC).

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