IBFAN AFRICA

Infant Feeding Issues

The WHO/UNICEF International Code

Please choose a topic below

 

What is the International Code?

Infant feeding in emergency situations:

Baby Friendly Hospital Initiatives (BFHI):

Community Support:

Maternity Protection:

Codex Alimentarius:

HIV and Infant Feeding:

 

What is the International Code? [Top]

The International Code of Marketing of Breastmilk Substitutes

The Member States of the World Health Organisation:

Affirming the right of every child and every pregnant and lactating woman to be adequately nourished  as a means of attaining and maintaining health;

Recognising that infant malnutrition is part of the wider problems of lack of education, poverty, and social injustice;

      Recognising that the health of infants and young children cannot be isolated from the health and nutrition of women, their socio-economic status and their roles as mothers;

Conscious that breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; that it forms a unique biological and emotional basis for the health of both mother  and child; that the anti-infective properties of breast milk help to protect infants against disease; and that there is an important relationship between breastfeeding and child spacing;

Recognising that the encouragement and protection of breastfeeding is an important part of the health, nutrition and other social measures required to promote healthy growth and development of infants and young children; and that breastfeeding is an important aspect of primary health care;

Considering that when mothers do not breastfeed, or only do so partially, there is a legitimate market for infant formula and for suitable ingredients from which to prepare it; that all these products should accordingly be made accessible to those who need them through commercial or noncommercial distribution systems; and that they should not be marketed or distributed in ways that may interfere with the protection and promotion of breastfeeding;

Recognising further that inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries, and that improper practices in the marketing of breastmilk substitutes and related products
can contribute to these major public health problems;

Convinced that it is important for infants to receive appropriate complementary foods, usually when the infant reaches four to six months of age, and that every effort should be made to use locally available foods; and convinced, nevertheless, that such complementary foods should not be used as breastmilk substitutes;

Appreciating that there are a number of social and economic factors affecting breastfeeding, and that, accordingly, governments should develop social support systems to protect, facilitate and encourage it, and that they should create an environment that fosters breastfeeding, provides appropriate family and community support, and protects mothers from factors that inhibit breastfeeding;

Affirming that health care systems, and the health professionals and other health workers serving in them, have an essential role to play in guiding infant feeding practices, encouraging and facilitating breastfeeding, and providing objective and consistent advice to mothers and families about the superior value of breastfeeding, or, where needed, on the proper use of infant formula, whether manufactured industrially or home prepared;

Affirming further that educational systems and other social services should be involved in the protection
and promotion of breastfeeding, and in the appropriate use of complementary foods;

Aware that families, communities, womens organisations and other nongovernmental organisations have a special role to play in the protection and promotion of breastfeeding and in ensuring the support needed by pregnant women and mothers of infants and young children, whether breastfeeding or not;

Affirming the need for governments, organisations of the United Nations system, nongovernmental organisations, experts in various related disciplines, consumer groups and industry to cooperate in activities aimed at the improvement of maternal, infant and young child health and nutrition;

 Recognising that governments should undertake a variety of health, nutrition and other social measures
to promote healthy growth and development of infants and young children, and that this Code concerns
only one aspect of these measures;

Considering that manufacturers and distributors of breastmilk substitutes have an important and
constructive role to play in relation to infant feeding, and in the promotion of the aim of this
Code and its proper implementation;

Affirming that governments are called upon to take action appropriate to their social and legislative framework and their overall development objectives to give effect to the principles and aim of this Code, including the enactment of legislation, regulations or other suitable measures;

Believing that, in the light of the foregoing considerations, and in view of the vulnerability of infants in the early months of life and the risks involved in inappropriate feeding practices, including the unnecessary and improper use of breastmilk substitutes, the marketing of breastmilk substitutes requires special treatment, which makes usual marketing practices unsuitable for these products;

 

THEREFORE:
The Member States hereby agree the following articles which are recommended as a basis for action.

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Article 1. Aim of the Code

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 2. Scope of the Code

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 breast-milk; feeding bottles and teats. It also applies to their
quality and availability, and to information concerning their use.

 

Article 3. Definitions

For the purposes of this Code:

"Breastmilk substitute" means any food being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not suitable for that purpose.

"Complementary food" means any food, whether manufactured or locally prepared, suitable as a
complement to breast milk or to infant formula, when either becomes insufficient to satisfy the nutritional requirements of the infant. Such food is also commonly called "weaning food" or "breastmilk supplement".

"Container" means any form of packaging of products for sale as a normal retail unit, including wrappers.

"Distributor" means a person, corporation or any other entity in the public or private sector engaged in the business (whether directly or indirectly) of marketing at the wholesale or retail level a product within the scope of this Code. A "primary distributor" is a manufacturers sales agent, representative, national distributor or broker.

"Health care system" means governmental, nongovernmental or private institutions or organisations engaged, directly or indirectly, in health care for mothers, infants and pregnant women; and nurseries or childcare institutions. It also includes health workers in private practice. For the purposes of this Code, the health care system does not include pharmacies or other established sales outlets.

"Health worker" means a person working in a component of such a health care system, whether professional
or nonprofessional, including voluntary, unpaid workers.

"Infant formula" means a breastmilk substitute formulated industrially in accordance with applicable Codex Alimentarius standards, to satisfy the normal nutritional requirements of infants up to between four and six months of age, and adapted to their physiological characteristics. Infant formula may also be prepared at
home, in which case it is described as "home prepared".

"Label" means any tag, brand, mark, pictorial or other descriptive matter, written, printed, stencilled, marked, embossed or impressed on, or attached to, a container (see above) of any products within the scope of this Code.

"Manufacturer" means a corporation or other entity in the public or private sector engaged in the business or function (whether directly or through an agent or through an entity controlled by or under contract with it) of manufacturing a product within the scope of this Code.

"Marketing" means product promotion, distribution, selling, advertising, product public relations, and
information services.

"Marketing personnel" means any persons whose functions involve the marketing of a product or products coming within the scope of this Code.

"Samples" means single or small quantities of a product provided without cost.

"Supplies" means quantities of a product provided for use over an extended period, free or at a low price, for social purposes, including those provided to families in need. 


Article 4. Information and education

4.1 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. This responsibility should cover either the planning, provision, design and dissemination
of information, or their control.

4.2 Informational and educational materials, whether written, audio, or visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young children, should include
clear information on all the following points:


1. the benefits and superiority of breastfeeding;
2. maternal nutrition, and the preparation for and maintenance of breastfeeding;
3. the negative effect on breastfeeding of introducing partial bottle feeding;
4. the difficulty of reversing the decision not to breastfeed; and
5. where needed, the proper use of infant formula, whether manufactured industrially or home prepared.

When such materials contain information about the use of infant formula, they should include the social and financial implications of its use; the health hazards of inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or improper use of infant formula and other breastmilk substitutes. Such materials should not use any pictures or text which may idealise the use of breastmilk substitutes.

4.3 Donations of informational or educational equipment or materials by manufacturers or distributors should
be made only at the request and with the written approval of the appropriate government authority or within guidelines given by governments for this purpose. Such equipment or materials may bear the donating companys name or logo, but should not refer to a proprietary product that is within the scope of this Code,
and should be distributed only through the health care system.

Article 5. The general public and mothers

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

5.2 Manufacturers and distributors should not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of products within the scope of this Code.

5.3 In conformity with paragraphs 1 and 2 of this Article, there should be no point-of-sale advertising, giving
of samples, or any other promotion device to induce sales directly to the consumer at the retail level, such as special displays, discount coupons, premiums, special sales, loss leaders and tie-in sales, for products within the scope of this Code. This provision should not restrict the establishment of pricing policies and practices intended to provide products at lower prices on a long-term basis.

5.4 Manufacturers and distributors should not distribute to pregnant women or mothers of infants and young children any gifts of articles or utensils which may promote the use of breastmilk substitutes or bottle feeding.

5.5 Marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind with pregnant women or with mothers of infants and young children.

 Article 6. Health care systems

6.1 The health authorities in Member States should take appropriate measures to encourage and protect breastfeeding and promote the principles of this Code, and should give appropriate information and advice to health workers in regard to their responsibilities, including the information specified in Article 4.2.

6.2 No facility of a health care system should be used for the purpose of promoting infant formula or other products within the scope of this Code. This Code does not, however, preclude the dissemination of information to health professionals as provided in Article 7.2.

6.3 Facilities of health care systems should not be used for the display of products within the scope of this Code, for placards or posters concerning such products, or for the distribution of material provided by a manufacturer or distributor other than that specified in Article 4.

6.4 The use by the health care system of "professional service representatives", "mothercraft nurses" or
similar personnel, provided or paid for by manufacturers or distributors, should not be permitted.

6.5 Feeding with infant formula, whether manufactured or home prepared, should be demonstrated only by health workers, or other community workers if necessary; and only to the mothers or family members who need to use it; and the information given should include a clear explanation of the hazards of improper use.

6.6 Donations or low-price sales to institutions or organisations of supplies of infant formula or other products within the scope of this Code, whether for use in the institutions or for distribution outside them, may be
made. Such supplies should only be used or distributed for infants who have to be fed on breastmilk substitutes. If these supplies are distributed for use outside the institutions, this should be done only by the institutions or organisations concerned. Such donations or low-price sales should not be used by
manufacturers or distributors as a sales inducement.

6.7 Where donated supplies of infant formula or other products within the scope of this Code are distributed outside an institution, the institution or organisation should take steps to ensure that supplies can be continued as long as the infants concerned need them. Donors, as well as institutions or organisations concerned, should bear in mind this responsibility.

6.8 Equipment and materials, in addition to those referred to in Article 4.3, donated to a health care system may bear a company’s name or logo, but should not refer to any proprietary product within the scope of this Code.

Article 7. Health workers

7.1 Health workers should encourage and protect breastfeeding; and those who are concerned in particular with maternal and infant nutrition should make themselves familiar with their responsibilities under this Code, including the information specified in Article 4.2.

7.2 Information provided by manufacturers and distributors to health professionals regarding products within the scope of this Code should be restricted to scientific and factual matters, and such information should not imply or create a belief that bottle feeding is equivalent or superior to breastfeeding. It should also include
the information specified in Article 4.2.

7.3 No financial or material inducements to promote products within the scope of this Code should be
offered by manufacturers or distributors to health workers or members of their families, nor should these
be accepted by health workers or members of their families.

7.4 Samples of infant formula or other products within the scope of this Code, or of equipment or utensils for their preparation or use, should not be provided to health workers except when necessary for the purpose of professional evaluation or research at the institutional level. Health workers should not give samples of infant formula to pregnant women, mothers of infants and young children, or members of their families.

7.5 Manufacturers and distributors of products within the scope of this Code should disclose to the institution
to which a recipient health worker is affiliated any contribution made to him or on his behalf for fellowships, study tours, research grants, attendance at professional conferences, or the like. Similar disclosures should
be made by the recipient. 

Article 8. Persons employed by manufacturers and distributors

8.1 In systems of sales incentives for marketing personnel, the volume of sales of products within the scope
of this Code should not be included in the calculation of bonuses, nor should quotas be set specifically for
sales of these products. This should not be understood to prevent the payment of bonuses based on the overall sales by a company of other products marketed by it.

8.2 Personnel employed in marketing products within the scope of this Code should not, as part of their job responsibilities, perform educational functions in relation to pregnant women or mothers of infants and young children. This should not be understood as preventing such personnel from being used for other functions by the health care system at the request and with the written approval of the appropriate authority of the government concerned.

                                                          

Article 9. Labelling

9.1 Labels should be designed to provide the necessary information about the appropriate use of the
product, and so as not to discourage breastfeeding.

9.2 Manufacturers and distributors of infant formula should ensure that each container has a clear, conspicuous, and easily readable and understandable message printed on it, or on a label which cannot
readily become separated from it, in an appropriate language, which includes all the following points:

1. The words "Important Notice" or their equivalent;
2. A statement of the superiority of breastfeeding;
3. A statement that the product should be used only on the advice of a health worker as to the need for its use and the proper method of use;
4. Instructions for appropriate preparation, and a warning against the health hazards of inappropriate preparation.

Neither the container nor the label should have pictures of infants, nor should they have other pictures or
text which may idealise the use of infant formula. They may, however, have graphics for easy identification
of the product as a breastmilk substitute and for illustrating methods of preparation. The terms "humanised", "maternalised" or similar terms should not be used. Inserts giving additional information about the product
and its proper use, subject to the above conditions, may be included in the package or retail unit.
When labels give instructions for modifying a product into infant formula, the above should apply.

9.3 Food products within the scope of this Code, marketed for infant feeding, which do not meet all the requirements of an infant formula, but which can be modified to do so, Should carry on the label a warning
that the unmodified product should not be the sole source of nourishment of an infant. Since sweetened condensed milk is not Suitable for infant feeding, nor for use as a main ingredient of infant formula, its label should not contain purported instructions on how to modify it for that purpose.

1. The ingredients used;
2. The composition/analysis of the product;
2. The storage conditions required; and
3. The batch number and the date before which the product is to be consumed, taking into account the climatic and storage conditions of the country concerned.

                                               

Article 10. Quality

10.1 The quality of products is an essential element for the protection of the health of infants and therefore should be of a high recognised standard.

10.2 Food products within the scope of this Code should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission and also the Codex Code of Hygienic Practice for Foods for Infants and Children.

                              

Article 11. Implementation and monitoring

11.1 Governments should take action to give effect to the principles and aim of this Code, as appropriate to their social and legislative framework, including the adoption of national legislation, regulations or other suitable measures. For this purpose, governments should seek, when necessary, the cooperation of WHO, UNICEF and other agencies of the United Nations system. National policies and measures, including laws and regulations, which are adopted to give effect to the principles and aim of this Code should be publicly stated, and should apply on the same basis to all those involved in the manufacture and marketing of products within the scope of this Code.

11.2 Monitoring the application of this Code lies with governments acting individually and collectively through the World Health Organisation as provided in paragraphs 6 and 7 of this Article. The manufacturers and distributors of products within the scope of this Code, and appropriate nongovernmental organisations, professional groups, and consumer organisations should collaborate with governments to this end.

11.3 Independently of any other measures taken for implementation of this Code, manufacturers and distributors of products within the scope of this Code should regard themselves as responsible for monitoring their marketing practices according to the principles and aim of this Code, and for taking steps to ensure that their conduct at every level conforms to them.

11.4 Nongovernmental organisations, professional groups, institutions, and individuals concerned should have the responsibility of drawing the attention of manufacturers or distributors to activities which are incompatible with the principles and aim of this Code, so that appropriate action can be taken. The appropriate governmental authority should also be informed.

11.5 Manufacturers and primary distributors of products within the scope of this Code should apprise each member of their marketing personnel of the Code and of their responsibilities under it.

11.6 In accordance with Article 62 of the Constitution of the World Health Organisation, Member States shall communicate annually to the Director General information on action taken to give effect to the principles and aim of this Code.

All IBFAN groups over the world are urged to strengthen monitoring to ensure companies comply. 

WHA Resolutions CLICK HERE




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Infant feeding in emergency situations:[Top]

Health care in emergency situation is a concern for families and programmes that aim to improve the health of women and children. In emergency and relief situations breastfeeding is of critical importance because it saves babies' lives. Most of the African countries are under political or civil strife. The diversity of target groups and the complexity of the humanitarian aid place women and children at a greater risk. IBFAN groups need to develop counseling skills on breastfeeding and emergency issues to respond adequately to emergencies. It is during these situations that baby milk companies may take the opportunity to build their image by providing free formula which is very dangerous under the emergency conditions. IBFAN members need to be watchful to see that companies comply with the conditions and spirit of the international Code of Marketing of Breastmilk Substitutes and Subsequent relevant Resolutions. IBFAN links its activities with those of the Interagency Group coordinated by GIFA. IBFAN Africa trains field workers using training modules developed by WHO, UNICEF, and IBFAN. 

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Baby Friendly Hospital Initiatives (BFHI):[Top]

Launched jointly by UNICEF and WHO in 1991, aims at giving babies the best start in life by creating an environment in which breastfeeding is the norm, beginning with a friendly and conducive atmosphere. The initiative is based on Ten Steps to Successful Breastfeeding which focuses on maternity services with the idea of protecting, supporting and promoting exclusive breastfeeding for the first six months of life, and encouraging continued breastfeeding for at least 2 years of the infant's life with adequate nutrition complements from locally available foods.

 

Maternity wards and hospitals which comply with global criteria for applying the set standards after being assessed are designated baby friendly. Through BFHI early initiation of breastfeeding as well as exclusive breastfeeding can be achieved.

The Ten Steps to Successful Breastfeeding

The BFHI promotes, protects, and supports breastfeeding through The Ten Steps to Successful Breastfeeding for Hospitals, as outlined by UNICEF/WHO. The steps are:

 
1 Maintain a written breastfeeding policy that is routinely communicated to all health care staff.

2 Train all health care staff in skills necessary to implement this policy.

3 Inform all pregnant women about the benefits and management of breastfeeding.
 
4 Help mothers initiate breastfeeding within one hour of birth.

5 Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

6 Give infants no food or drink other than breastmilk, unless medically indicated.
 
7 Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.

8 Encourage unrestricted breastfeeding.

9 Give no pacifiers or artificial nipples to breastfeeding infants.
 
10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
 

 

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Community Support:[Top]
This is an extension of the BFHI to the communities by implementing the 10th step of the Ten Steps to Successful Breastfeeding. It is a way in which breastfeeding programmes are incorporated into community activities. There is an extension of actions initiated by health workers in maternity wards and hospitals. Mother to mother support systems are formed by local NGO's. Through these mother-to-mother support systems which are normally composed of mothers who have successfully breastfed, experiences are shared on exclusive breastfeeding and appropriate introduction of complementary feeding. This is one way in which BFHI is encouraged and sustained within communities. IBFAN Africa developed a Community based manual as a teaching Aid for health workers in communities in Africa.

 
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Maternity Protection:[Top]
 The recommended practice for breastfeeding is to breastfeed exclusively for six months. However this is sometimes seen as impossible for working mothers who have to return to work shortly after delivery. Most African countries have varied maternity leave and its entitlement for their women workforce. Mothers also need time to recover after delivery. The goal is to advocate for extended maternity leave where possible, of up to six months. There is also need to introduce Paternity leave so that parents can share the care of infants in the early life of the baby. IBFAN continues advocacy for improved women rights including longer maternity leave, the right to be paid when on leave and the right to keep her job. These includes all the other maternity benefits in the new ILO Convention 183, 2000 on Maternity Protection, and recommendation 191

 

Related weblink

http://www.ilo.org/global/lang--en/index.htm

From the 1998 Calendar of National Food & Nutrition Commission of Zambia

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Codex Alimentarius:[Top][Top]

The food Code was created to protect consumer's health, to ensure fair food trade practices and to facilitate international trade.

Codex Alimentarius (CA) is a worldwide food code that guarantees:

Safe wholesome products free from adulteration;
Correct labeling; and
Correct presentation.
The Codex Alimentarius Commission, the Joint Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO) foods standards Programme, deal with different commodity standards, some of these relate to infant and young child foods. Examples of these are the standards for processed Cereal-Based Foods for Infants and Young Children, and the Standard for Infant Formula. The two standards are very important for the fact that they are both linked to the Protection of breastfeeding.

The benefits of breastfeeding are many and applicable to both rich and the poor. It provides optimal nutrition and health for infants and young children. Further more, breastfeeding has both short term and long term benefits which include of the mother, financial gains on society by reducing health care costs as well as the cost of formula to replace the breast, and finally it is the basis for a healthier society.

Secondly, the two standards are very important to the infant and young child nutrition as artificially-fed infants need consumer protection.

The health risks of artificial feeding are many and should therefore be minimised as much as possible by making available the best attainable product. These products should be based on scientific evidence and on the best technology available.

The promotions of artificial feeding products are misleading and seduce parents to artificially feed their infants unnecessarily. Artificial feeding products should be only for infants that truly need them. The manufacture and marketing of artificial infant feeding products must comply with the International Code.

Thirdly, the issue of consumer protection is also involved. Infants and young children cannot make decisions about feeding for themselves. They constitute a vulnerable group of consumers who need special protection. Parents are entitled to unbiased information about infant feeding products.

The Standard for Processed Cereal-based Foods for Infants Young Children, which sets the criteria for cereal-based complementary food products, and standard for infant formula are major standards of interest to IBFAN groups contains a number of areas for concern to IBFAN groups.

IBFAN wants to see changes in the definitions under scope, which defines the food products covered by the standard in generic terms.

Under Essential Composition and Quality Factors, IBFAN members would like improvement on various areas such as:

Nutritional quality;
Age of introduction of complementary foods to be 6 months;
Labelling - to be based on the International Code and WHO Resolutions;
Removal of health claims; and
Avoidance of biotechnology use for infant foods.

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HIV and Infant Feeding: [Top]
Of critical importance is the HIV/AIDS issue as it affects infant feeding. Africa is the continent most affected and with the industry waiting to cash on this misfortune. IBFAN is contributing to the prevention and reduction of Mother to Child Transmission of HIV/AIDS (MTCT) by guiding appropriate actions. For example IBFAN has developed position statements and policy guidelines on infant feeding in the context of HIV and now supports countries initiatives in developing suitable policies. Information is disseminated on MTCT of HIV and IBFAN supports WHO and UNICEF to train national groups on counseling on HIV and infant feeding. There is also advocacy for independent research on HIV/AIDS and infant feeding issues. See the following reports:

Protection, Support and Promotion of Breastfeeding in HIV: policy guidelines, 2000, Pretoria, South Africa.
Protection of Breastfeeding in HIV/AIDS: A Report of Proceedings of the IBFAN Africa Regional Workshop to Develop Policy Guidelines for Infant Feeding in HIV, Pretoria, South Africa, August 1999.
IBFAN Africa Position Statement on HIV and Infant Feeding 1997 and 1999.