International Code of Marketing of Breast-milk Substitutes

Module 1: Infant and Young Child Feeding

The importance of optimal infant and young child feeding for survival, growth and development

Improving breastfeeding and complementary feeding practices rank among the most effective
interventions to improve child health. In 2015, and estimated 5.9 million children died before their
fifth birthday, with close to 75% of these deaths occurring within the first year of life. Malnutrition is
responsible, directly or indirectly, for at least 45% of under-five deaths. It is also a major disabler,
preventing children from reaching their full developmental potential.

Nutrition and nurturing during the first years of life are both crucial for life-long health and well-
being. Improving breastfeeding practices, especially, exclusive breastfeeding for the first 6 months of
life, has the potential to prevent over 820,000 annual deaths in children under 5 globally (87% of
them among infants less than 6 months of age), as well as about 20,000 additional deaths from
breast cancer each year. Exclusive breastfeeding also has the long-term benefits of reducing risk
factors for diabetes and overweight in adulthood. It has also been linked with reduced risk of
infection in infants, and a higher IQ later in life. (Lancet, 2016)

Optimal infant and young child feeding

The global public health recommendation for optimal infant and young child feeding is that infants
should be exclusively breastfeed for the first six months of life and thereafter should receive
nutritionally adequate and safe complementary foods while breastfeeding continues for up to two
years or beyond. (WHO, Global Strategy for infant and young child feeding, Geneva 2003).

Early initiations: babies are placed in skin-to-skin contact with their mothers immediately following
birth for at least an hour and mothers are encouraged to recognize when their babies are ready to
breastfeed, offering help if needed. (eLENA, 2016).

Exclusive breastfeeding: an infant receives only breast milk with exceptions only for oral
rehydration solution, drops or syrups that contain vitamins, minerals supplements or medicines.
(WHO/UNICEF/USAID, 2008)

Complementary feeding: the process beginning when breast milk alone is no longer sufficient to
meet the nutritional requirements of infants, and therefore other foods and liquids are needed,
along with breast milk. (PAHO/WHO, 2004)

Breast milk contains all the nutrients that an infant needs, including fat, carbohydrates, proteins,
vitamins, minerals and water. It is easily digested and efficiently used. Breast milk also contains
bioactive factors that augment the infant’s immune system, providing protection against invention,
and other factors that help digestion and absorption of nutrients. Infant formula, the predominant
substitute for mother’s milk, can only replace some of the known nutritional components of breast
milk. Even so, the right combination of nutrients found in breast milk is not replicated in infant
formula. “[Infant formula] is just a food, whereas breast milk is a complex living nutritional fluid
containing anti-bodies, enzymes, long chain fatty acids and hormones, many of which simply cannot
be included in formula.” (https://www.unicef.org/nutrition/index_24824.html)
Benefits of breastfeeding
International recommendations call for infants to be exclusively breastfeed for the first six months
of life. During those first 6 months, breast milk fulfills the energy and nutrient needs of the vast
majority of infants. No other foods or fluids are necessary, not even water.

Infants who are not exclusively breastfeed are at an increased risk of diarrhea and other acute
infections, such as pneumonia, otitis media, Haemophilus Influenza meningitis and urinary tract
infections.
Some other benefits of breastfeeding, which affect not only health and wellbeing of the infant but
also that of the mother, include:

 Promotes special bonding between mother and child leading to lifelong development
benefits and a special emotion relationship
 Lower risk of chronic conditions in later life including obesity, diabetes, and childhood
leukaemias
 Higher performance on intelligence tests later in life
 Breast milk is free and eliminates or reduces the need to purchase breast-milk substitutes
 Breastfeed babies are sick less often, thus reducing healthcare costs to the family for office
visits, prescriptions, over-the-counter medicines and hospitalizations
 Helps the uterus to contract thus reducing the risk for the mother of postpartum bleeding
immediately after delivery
 Reduced risk of breast and ovarian cancers
 Exclusive breastfeeding also helps the mother’s body delay the return of fertility and
therefore helps with natural birth spacing

During the first six months, introducing foods and fluids in addition to breastfeeding, also called
mixed feeding, can reduce a mother’s breast milk supply because the baby suckles less at the breast.
Exclusive breastfeeding, as compared to mixed feeding, is also associated with significantly lower
risk of transmission of HIV from mother to child during the first six months.

Importance of Continued Breastfeeding for the first 2 years

When an infant reaches the age of six months, the need for energy and nutrients begins to exceed
that provided by breast milk. Other foods in addition to breast milk become necessary to fill the gap.
If complementary foods are not introduced at this age or if they are given inappropriately, an
infant’s growth may falter. In many countries, the period of complementary feeding from 6-23
months is the time of peak incidence of growth faltering, micronutrient deficiencies and infectious
illnesses. Complementary foods need to be nutritionally adequate, safe, and appropriately fed in
order to meet the young child’s energy and nutrient needs.

During the first two years of lfie, breastfeeding remains a critical source of nutrients for the infant
and young child. It provides about one half of an infant’s energy needs up to the age of one year,
and up to one third during the second year of life. Breast milk continues to supply higher quality
nutrients than complementary foods, and also continues to protect the child from infection and
disease.

Risk of Infant Formula

Many mothers replace their breast milk with infant formula or other substitutes, a practice which,
particularly in poor conditions, can easily to lead to illness and death. Artificial feeding, to minimize
risk, requires access to clean water and fuel and facilities for cleaning and sterilizing feeding utensils,
especially if feeding bottles are used. Feeding bottles carry a high risk of contamination that can lead
to lfie-threatening infections in young infants. Safe feeding with breast-milk substitutes also requires
adequate income to purchase sufficient quantities as well as the ability to read and follow
preparation instructions. Moreover, infant formula is not a sterile product and it may carry
Enterobacter Sakazakii and other pathogens that can cause fatal disease such as sepsis and
meningitis in small or immune-compromised infants.

Breastfeeding prevalence around the world

Today, it is estimated that only about 2 out of 5 infants are put to the breast within the first hour of
life, and about 43% are exclusively breastfeed for the first six months, globally (UNICEF Statistics,
2016). Only half of all 20-23 month olds benefit from the practice of continued breastfeeding/

The world has varying levels of success for breastfeeding at 12 months of age, as you can see below.
This map came from the Lancet series on breastfeeding in 2016, which pointed out the need to
make breastfeeding a one-world issue, and not concentrate efforts only on developing regions.

Internatioanl efforts to improve infant and young child feeding practices

The World Health Assembly’s (WHA) adoption of the International Code of Marketing of Breast-milk
Substitutes (the Code or the International Code) in 1981 was the first of a series of international
initiatives and programs directed at improving infant and young child feeding practices—
recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats.
The code: ensuring that information about infant feeding is objective, correct and consistent, and
removing commercial pressures to use substitutes for breast milk.

The Innocenti Declaration

Adopted in 1990 by a group of high-level policymakers from 32 countries and 10 UN Agencies and
lays out the following 4 targets for all governments as a way of reinforcing a “breastfeeding culture”:

 Appointing a national breastfeeding coordinator with appropriate authority, and

establishing a multisectoral national breastfeeding committee composed of representatives
from relevant government departments, nongovernmental organizations, and health
professional associations;
 Ensuring that every facility providing maternity services fully practices all the “Ten steps to
successful breastfeeding”
 Giving effect to the principles and aim of the International Code of Marketing of Breast-milk
Substitutes and subsequent relevant Health Assembly resolutions in their entirety; and
 Enacting imaginative legislation protecting the breastfeeding rights of working women and
establishing means for its enforcement.

Baby Friendly Hospital Initiative (BFHI)

Created in 1991 by WHO and UNICEF and is aimed specifically at the second goal of the
Innocenti Declaration, promoting of the “Ten steps to successful breastfeeding” in hospitals
worldwide. It is designed to remove hospital barriers to breastfeeding by creating a supportive
environment with trained and knowledgeable health workers. It has been implemented by
countries all over the world and allows hospitals to distinguish themselves as BFHI certified
based on the Ten Steps.

Global Strategy for Infant and Young Child Feeding

endorsed by WHA Member States and the UNICEF Excecutive Board in 2002. The strategy builds
on the Innocenti Declaration, the Code and the BFHI and provides the framework for efforts to
protect, promote and support appropriate infant and young child feeding. It is based on
recognized human rights standards, particularly the rights to adequate nutrition and to be
informed about nutrition, and the advantages of breastfeeding. These are crucial components of
the child’s right to the highest attainable standard of health as set forth in the Convention on
the Rights of the Child.

Innocenti Declaration 2005

Progress as well as the continuing threat to child health and survival posed by inappropriate
feeding practices. This is a call to action for governments, industry and other organizations for
Code implementation among other vital measures for improving feeding practices.
In May of 2012, the WHA endorsed the Comprehensive Implementation Plan on Maternal,
Infant and Young Child Nutrition (MIYCN) which includes 6 global target to achieve by 2025 and
5 actions to support attainment of the goals. UNICEF and WHO formed a Breastfeeding
Advocacy Initiative (BAI) in conjunction with other partners to increase investment and
commitment in breastfeeding as a foundation for child nutrition, health and development in
2015. Among other advocacy efforts, the BAI encourages countries to implement and monitor
the Code at the national level.