841

W.H.O./UNICEF MEETING

The long-awaited W.H.O./UNICEF meeting1 on in-fant and young-child feeding was held in Geneva onOctober 9-12. It was a private gathering of delegationsnominated by 23 Governments,2 members of U.N. andspecialised agencies and of concerned non-Governmen-tal organisations, representatives of the infant-food in-dustry, and individual scientists. What follows has

necessarily been based only on documents issued before,during, and after the meeting. An editorial appears onp. 833. -

IN his opening statement, the chairman, Dr FRED SAI,interregional coordinator of the World Hunger Pro-gramme, declared that infant and young-child malnutri-tion should be considered a blot on our times, ourscience and technology, our social structures, and all ofthe so-called development achievements in which wetook so much pride. After three decades of trying wewere now confronted with an alarmingly increasinggrowth in the numbers who were not having adequatenutritional sustenance, so there had to be somethingwrong with our structures, international or national,and with the channels for carrying technology andscience to the areas where they should matter. It some-times looked as if developed and developing countriestalked as though they did not belong to the same planet.No matter what the feeling, or what the rhetoric, thepoor seemed to be getting more and more poor and moreand more caught up in the game of the rhetoric whichnobody seriously wanted to see translated into action.In the great problem of malnutrition, the major"players" were powerless. By and large the meeting wasconcerned with the rural poor and the urban poor, the

people whom politicians, even in developing countries letalone in the international field, considered simply as

mere votes. They were brought alive and made to feelimportant during electioneering. They were given a fewthings, they were given a lot of hope; and, once theirvotes were taken and the power wielders elected, thatwas the end of the issue. Dr Sai urged the meeting notto look back and discuss past debates. The problem wastoo urgent, and "it must be too challenging for us todwell on this kind of activity for which we will stand infront of history and be judged as having failed just asmuch as some of the other past meetings and confer-ences have failed."

.

Recommendations

The views and proposals which emerged from themeeting included:

ENCOURAGEMENT AND SUPPORT OF BREAST-FEEDING

During PregnancyThe nation’s health-care systems, in collaboration with other

sectors, should help in identifying and utilising existing localresources to ensure that the nutritional needs of mothers aremet. All mothers, particularly during pregnancy, should be

systematically provided with practical breast-feeding educationin keeping with their life situations. With adequate teachingand support almost all mothers are capable of breast-feedingand solving any problems which may arise. The best teacherswill be breast-feeding mothers. All health workers in a positionto provide adequate information on breast-feeding should becommitted to the promotion of breast-feeding and have athorough knowledge of its management. Care should be givenduring pregnancy to identifying those mothers who are likelyto be at high risk of not breast-feeding, and special attentionshould be paid to them.

Delivery

Unnecessary sedation, routine episiotomy, and routine useof lactation suppressants should be avoided. Breast-feedingshould be initiated as soon after birth as possible, normallyduring the first half-hour. Mothers should be encouraged andpermitted to keep their infants with them and to practise on-demand feeding. The role of the father and other members ofthe extended family in supporting the mother should be

emphasised in all prenatal, maternity, and postnatal care.

After DeliveryAll postnatal health care should be oriented towards ensur-

ing the maintenance of breast-feeding for as long as possible.All babies should receive colostrum. The use of supplementarybottle-feeding (water and formula) should be avoided. A

healthy well-nourished mother who is fully breast-feeding herinfant should not need to introduce any complements duringthe first 4-6 months of life.

The contraceptive effect of breast-feeding should be wellrecognised, although additional family-planning methodsshould be promoted. Preference should be given to contracep-tive methods which do not interfere with the normal processoflactation.

Where it is not possible for the biological mother to breast-feed, the first alternative, if available, should be the use ofhuman breast milk from other sources. Human milk banksshould be made available in appropriate situations.

A baby who is not breast-fed should receive special attentionfrom the health-care system. Adequate instructions for the useof infant foods, as well as warnings about its problems, shouldbe the responsibility of the health-care system. Supplies of in-fant formula would thus be required for distribution onlywhere necessary and not as a routine.

Creches, paid breast-feeding breaks, and other facilitiesshould be provided, wherever appropriate, in industry, and inother relevant institutions, or close to the place of work to per-mit mothers to continue breast-feeding and have close contactwith their babies.

WEANING PRACTICES AND USE OF LOCAL FOOD RESOURCES

Food complementary to breast milk will need to be intro-duced by 4-6 months; when the nutrition of the mother is poorand/or environmental conditions are unfavourable it mayoften need to be introduced earlier. However, too early intro-duction may have a negative effect on breast-feeding and mayalso increase the risk of infection. Foods locally available in thehome can be made suitable for weaning and their use shouldbe strongly emphasised in health, education, and agriculturalextension programmes. Foods traditionally given to infantsand young children in some populations are often deficient innutritional value and hygiene, and need to be improved in var-ious ways. Mothers need guidance to improve these traditionalfoods, through combinations with other foods available to

842

’them locally. Countries should determine the need for subsidis-ing weaning foods or otherwise helping to ensure their avail-ability to low-income groups.

Governments and private or public organisations shouldsupport practical initiatives and policies for improving thenutritional value and hygienic standards of traditional andother locally used weaning foods, for achieving a balanced dietfor infants, for educating mothers in the proper feeding ofchildren, and for facilitating the exchange of weaning andchild-feeding experiences among countries.

To avoid infection and interference with continued breast-

feeding, infants during weaning should not be fed by bottle butrather by cup and spoon or other suitable traditional vesselsand utensils. When mothers do not initiate breast-feeding orterminate it prematurely, so that animal milk or perhaps vege-table milk mixtures or products may need to be fed by bottle,competent guidance should be available to ensure that the mix-ture or product is nutritionally adequate, both in quantity andquality, and that all possible measures are taken to see that itdoes not become a vehicle for infection.

Psychological, social, and economic factors that constrainbreast-feeding should be minimised.

EDUCATION, TRAINING, AND INFORMATION

In all educational (formal and non-formal), vocational, andprofessional training programmes, the interrelationship of allknowledge about health protection, breast-feeding, and ade-quate nutrition of the mother, infant, and child should befeatured. Educational and informational activities aboutnutrition must be: adapted to local conditions and culture;supported by necessary resources from those sectors respon-sible for periurban and rural economic development; andlinked to measures for income-generation at family and com-munity level.

Nutrition education and information should also be pro-vided to those who are influential with the family, such asfathers, grandparents, mother-surrogates, communityteachers, and others who have an impact on the social behav-iour and nutritional habits of vulnerable groups. Governmentsshould provide adequate nutrition training in medical andnursing schools and adequate training for primary-health-careworkers, including midwives, particularly in prenatal and peri-natal services, schoolteachers, rural extension workers, andothers operating at the community level to enable them to un-dertake functional health and nutrition education in the com-

munity, based on the priority needs of the people and withtheir active participation.

Basic and continuing education and upgrading of informa-tion on all aspects of breast-feeding is necessary for health-ser-vice staff at all levels. Training should place emphasis on man-agement of breast-feeding and on available, culturallyacceptable, and locally grown food suitable for weaning and forsupplementing the diet of pregnant and lactating women. Staffshould also be enlightened about the dangers and hazards ofadvertising infant foods in clinics.

The use of mass media, which in many countries includesradio, television, newspapers, and advertisements for formulaand other infant-food products in Government and profes-sional journals, should be effectively screened to ensure thatthey do not detract from official nutrition policies designed toprotect breast-feeding or from the health and nutritional statusof mothers and children.

Much more information is needed about the present state ofeducation/training in maternal, infant, and young-child nutri-tiori throughout the world.

IMPROVED HEALTH AND SOCIAL STATUS OF WOMEN

Women’s participation in all these areas must be signifi-cantly increased through: (i) their increased representation inall recommended actions, including increased involvement inthe activities of United Nations agencies, non-Governmentalorganisations, and other groups, including industry and tradeunions; (ii) the increased recognition and involvement ofwomen’s organisations in community, national, and interna-tional efforts; (iii) the increased involvement of women in

policy formulation and decision-making at all stages of plan-ning and implementation of related national programmes.

Improved infant and young-child feeding is closely linkedwith a high status of health throughout a woman’s life, es-pecially in’ the reproductive cycle. Special attention should begiven to reproductive health and education of adolescent girls.Women’s workload should be reduced, both in and outside thehome.

Governments should ratify and apply the I.L.O. conventionsthrough national legislation concerning maternity protectionfor facilitating breast-feeding (paid nursing breaks, !1exibleschedules, day-care centres, and other measures to ensure thephysical closeness of mother and child). A nursing women’searnings should not be substantially reduced. Any discrimina-tion against nursing mothers in employment should be prohi-bited.

MARKETING AND DISTRIBUTION OF INFANT FORMULA AND

WEANING FOODS

Marketing of breast-milk substitutes and weaning foodsshould be designed not to discourage breast-feeding. Thereshould be no sales promotion, including promotional advertis-ing to the public, of products to be used as breast-milk subst-tutes or bottle-fed supplements and feeding bottles This restric-tion would include the use of mass media and other forms of

advertising directly to the mother or general public, designedto increase sales of breast-milk substitutes, to the detriment ofbreast-feeding. Promotion to health personnel should be res-tricted to factual and ethical information.

There should be an international code of marketing of in-fant formula and other products used as breast-milk substi-tutes. Such a code should be supported by both exporting andimporting countries and observed by all manufacturers.W.H.O./UNICEF are requested to organise the process for itspreparation, with the involvement of all concerned parties, inorder to reach a conclusion as soon as possible.

Monitoring of marketing practices is recommended-

usually to be conducted under Government auspices. Advertis-ing councils and industry, consumer, and professional groupscan make an inportant contribution.

’

There should be no marketing or availability of infant for-mula or weaning foods in a country unless marketing practicesare in accord with the national code or legislation if these exist,or, in their absence, with the spirit of the Geneva meeting andits recommendations or with any agreed international code.No personnel paid by companies producing or selling breast-

milk substitutes should be allowed to work in the health-care

system, even if they are assigned more general responsibilitiesthat do not directly include the promotion of formulas, inorder to avoid the risk of conflict of interest.

Products that are not suitable alone as weaning foods, suchas sweetened condensed milk, corn starch, cassava flour, andcereal flours, should be required by regulations not to be pack-aged, labelled, advertised, or otherwise promoted in ways thatsuggest they should be used as a complement or substitute forbreast milk. Vigorous educational efforts should be made

against their misuse for the purpose by mothers.

843

The Approach of the IndustryBefore the meeting the International Council of In-

fant Food Industries3 set out its views in a statement

from which the following passages have been taken:

All members of ICIFI would concentrate on the positive andkeep the health and wellbeing of infants in the forefront oftheir discussions. Now was not the time for polarisation andrecrimination by any of the groups at the meeting. Now wasthe time to bring real meaning to the concept of "shared re-sponsibility" so that Governments, health professionals, the in-fant-formula industry, and concerned consumer groups couldidentify their respective roles and work together to improve in-fant nutrition.

In its Statement 23 of July, 1972, the United Nations Pro-tein Advisory Group (P.A.G.) proposed recommendations toassist Governments and U.N. agencies, health professionalsand the infant-food industry in dealing with the promotion ofspecial infant foods on an objective and effective basis. Thecritical importance of breast-feeding was the central focus ofStatement 23. But P.A.G. recognised that breast-feeding alonewas not the answer to malnutrition: "It is clearly important toavoid any action that would accelerate the trend away from

breast-feeding; at the same time, it is essential to make for-mulas, foods and instructions for good nutrition of their in-fants available to those mothers who do not breast feed for var-ious reasons." One of the most important issues which themeeting had to address was the identification of the need forinfant foods other than breast milk. This issue was not breastv. bottle; the issue was identifying the nutritional needs of agrowing infant and how they could best be satisfied.

The W.H.O./UNICEF working paper circulated before themeeting contained a comprehensive review of the main topicsto be discussed at the meeting. There were three key issues towhich the paper gave, in ICIFI’s view, inadequate treatment.They were: the extent of the need for nutritionally adequateinfant foods to supplement breast milk; the recognition of in-dustry’s role in the shared responsibility for better infantnutrition; and the development of local codes of practiceapplicable to the infant-food industry.The members of ICIFI had committed themselves to five in-

itiatives :

(1) To propose an objective scientific analysis of total current knowl-edge on infant nutrition to be conducted by paediatricians, nutri-

tionists, and researchers with experience of the developing countries inconsultation with health advisers to Third World Governments.

(2) To support appropriate new research projects to fill important in-formation gaps which may be identified at the W.H.O./UNICEF meet-ing, or from scientific sources.

(3) To offer its expertise to Governments in the development of pro-grammes to educate mothers on sound infant feeding, includingbreast-feeding, hygiene, maternal diet, proper use of supplements.

(4) To collaborate with individual Governments to adopt preciselyworded and workable national codes of conduct and to participate inworking groups which maintain a dialogue among industry, healthprofessionals, governments, and consumer groups.

! 5) To support the concept of shared responsibility m developing pro-grammes designed to improve infant health.

ICIFI called on those companies not yet among its membersto join in these initiatives and to accept the disciplines whichthe existing membership had imposed upon itself, as a clear de-monstration of industry’s commitment to operate in the publicinterest.

W.H.O. Collaborative Study on Breast-feeding

This study has been initiated and developed by W.H.O. inorder to secure a reliable and objective picture of current prac-

tices of infant feeding, with special reference to breast-feedingin various parts of the world. The study is in two phases. Thefirst phase examined patterns of breast-feeding and major fac-tors which might affect breast-feeding practices in varioussocioeconomic groups in different parts of the world. This in-formation was mainly obtained in 1975-77 from mother-and-child pairs in at least three socioeconomic groups in each of9 countries (Hungary, Sweden, Ethiopia, Chile, Guatemala,Phillipines, India, Nigeria, and Zaire). The second phase of thestudy is concerned with the volume and composition of breastmilk and with maternal health and socioeconomic character-istics. The overall aim of the study was to obtain a factualbasis for more effective educational and other programmes topromote improved health and nutrition of infants and youngchildren.

A preliminary report,’ prepared for last week’s meeting, setsout the methods employed and some of the main findings of thefirst phase. The full publication of the first phase will follow.In a later issue The Lancet will give some impressions emerg-ing from the preliminary report. The second phase is now un-der way in 6 of the 9 countries and results are expected to beavailable by the end of 1980.

War on Want’s New Investigation

War on Want is a campaign against world poverty. It wasresponsible for the report in 1974 which led to the intensifica-tion of pressure against the promotion and sale of industriallyprepared breast-milk substitutes and which was one of the stim-uli which prompted last week’s meeting. A new investigation,5 5

published on Oct. 4 as part of the campaign’s support for theW.H.O./UNICEF meeting, sets out the evidence for the viewthat many of the commercial practices condemned five yearsago are still operating. It records instances of abuse of com-pany codes of ethics; and it points again to the dangers of dis-tributing breast-milk substitutes and processed weaning foodsin parts of the world where mothers may have no runningwater and no modern cooking facilities, where the instructionson the containers may not be fully understood, and wherechildren may be undernourished when the food is overdilutedbecause it is too heavy an item in family expenditure. Examin-ing the role of the health profession in infant and child feedingin the Third World, the report concludes: "Many sources havepointed out that it is necessary for the profession to look muchmore critically at the inducements offered to it by the industry,and realise the degree of manipulation and influence the in-dustry has achieved over the years. It should be the task of anuncommitted health profession to produce-the necessary edu-cational material on feeding practices, both for the public andfor its own members. The practice of allowing the industry toinform both the public and the profession of new developmentsin infant nutrition, either directly through promotional leaf-lets, or indirectly through its sponsorship of meetings, confer-ences and seminars has been pointed out as a dangerous onethat should be curbed. The profession also has a responsibilityto encourage and put into practice changes in the maternitycare facilities throughout the world that will lead to better en-vironments for successful breast feeding..."

REFERENCES

1. Editorial. Uneasy prelude to meeting on infant feeding. Lancet 1979; ii:680-81.

2. Note. Geneva meeting on infant feeding. Lancet 1979; ii: 704.3. Anonymous. International Council of Infant Food Industries: its aims and

progress. Lancet 1978; i: 1250-52.4. World Health Organisation. MCH/79.3. Geneva, 1979.5. The Baby Killer Scandal: a War on Want investigation into the promotion

and sale of powdered baby milks in the Third World. By ANDY CHETLEY.Pp. 176. 1979. Obtainable (£1.50 plus postage) from War on Want,467 Caledonian Road, London N7 9BE.