The International Code of Marketing of Breastmilk Substitutes in Emergencies

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The International Code of Marketing of
Breast-milk Substitutes in Emergencies

• A minimum standard

David Clark, Nutrition Section, NYHQ
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Outline

• Why do we need the Code?
• What is the Code? What does it say?
• What does the Code say about infant feeding in
  emergencies
• Implementing the Code in emergencies the
  Operational Guidance
• Conclusions

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Why do we need the Code?
Breastfeeding saves lives
Estimated that 1.3 million additional lives would
be saved and millions more enhanced every year if
every baby were exclusively breastfed from birth
for six months (Lancet series on Child Survival,
2004).
Photo Flora Sibanda Mulder
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Breastfeeding Saves Lives- Relative risk of
infectious disease mortality among non-breastfed
infants
5.8
WHO, Lancet 2000
4.1
2.6
1.8
1.6
1.4
Age (months)
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In emergencies, breastfeeding becomes even more
important

• In emergencies, children under five are more
  likely to become ill and die from malnutrition
  and disease than anyone else. In general, the
  younger children are, the more vulnerable they
  are. Inappropriate feeding increases their risks
  of death and disease.
• Breastmilk substitutes carry risks of increased
  illness and mortality in the best of
  circumstances. Where there is poor hygiene lack
  of access to clean water uncertain supplies of
  substitutes etc., the use of breastmilk
  substitutes becomes even more dangerous.

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Intrinsic Contamination of Formula

• Powdered infant formulas are NOT sterile products
• They can become contaminated at factory level
  with heat resistant, pathogenic bacteria
• Enterobacter sakazakii is highly virulent and
  found in infant formula

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Yet unsolicited donations of formula are common
Thursday, 23 August 2007, 2155 GMT 2255 UK
Countries across Latin America have been sending
relief supplies to Peru
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• Unsolicited formula poured into Indonesia
  following 2005 tsunami in Aceh and 2006
  earthquake in Jogjakarta. Post-earthquake survey
  showed dramatic increase in formula feeding
  compared to pre-earthquake situation (27 to 80)

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Corporate philanthropy?

• January 25, 2005
• Gordonsville, Va. - As a result of a generous
  corporate donation, a large amount of infant
  formula, including products produced at the PBM
  Nutritionals plant in Georgia, Vt., will be
  heading to victims of the tsunami.
• Bright Beginnings Nutritionals, makers of Bright
  Beginnings Baby Formula with DHA (docosahexaenoic
  acid), the fastest growing infant formula in the
  U.S., announced today that it is donating infant
  formula and pediatric nutritional drinks to the
  victims within the Indian Ocean disaster area.

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Relevance of the Code

• The Code aims 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.

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What is the Code?

• adopted by World Health Assembly Resolution in
  May, 1981
• global recommendation - All States urged to
  incorporate into national legislation.
• companies urged to ensure their practices comply
  with the Code at all levels.
• Code further clarified and augmented through
  subsequent World Health Assembly Resolutions

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International Code of Marketing of Breastmilk
Substitutes a summary of main points and
examples of violations
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No advertising of breastmilk substitutes to the
public.
Very close to the original.
Almost a Breastmilk.
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No free samples to mothers
Indonesia
Thailand
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No promotion in shops
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No gifts to mothers
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No free or low-cost supplies in healthcare
facilities
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No promotion in healthcare facilities
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No gifts or personal samples to health workers.
Health workers should never pass samples on to
mothers
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No pictures of infants, or other words or
pictures idealising artificial feeding, on labels
DHA and ARA composition is closest to that of
breastmilk.
Recommended for use from one week.
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• Information on artificial feeding should explain
  benefits superiority of breastfeeding, costs
  dangers of artificial feeding.

Vietnam
Lactogen good for brain, bones and body
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Information to health workers should be
restricted to scientific and factual information.
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Promotion to health professionals in Thailand
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• Code does not restrict the availability of
  breastmilk substitutes, feeding bottles or teats,
  only how they are marketed
• Code does not prohibit the use of bms during
  emergencies, only the way in which they are
  procured and distributed
• Code is intended to protect artificially fed
  babies by ensuring bms will be used as safely as
  possible on the basis of impartial, accurate
  information

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Infant Feeding in Emergencies WHA Resolution
47.5 (1994)

• Urges Member States
• to exercise extreme caution when planning,
  implementing or supporting emergency relief
  operations, by protecting, promoting and
  supporting breast-feeding for infants, and
  ensuring that donated supplies of breast-milk
  substitutes or other products covered by the
  scope of the International Code be given only if
  all the following conditions apply

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Conditions

• infants have to be fed on BMS, as outlined in the
  guidelines concerning the main health and
  socioeconomic circumstances in which infants have
  to be fed on breast-milk substitutes (Document
  WHA39/1986/REC/1, Annex 6, part 2)
• the supply is continued for as long as the
  infants concerned need it
• the supply is not used as a sales inducement

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Current Policy Framework

• 2001 Operational Guidance (OG) for Emergency
  Relief staff and Programme Managers developed by
  Interagency Core Group on Infant Feeding in
  Emergencies and endorsed by over 30 agencies and
  organisations
• The OG has been revised based on the 5 year
  experience with its implementation and the 2007
  version is available at www.ennonline.net

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Also available in Arabic, French, Portuguese and
Spanish
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6 Minimise the Risks of any Artificial Feeding
In emergencies, donations of BMS not needed and
may put infants lives at risk. This information
should be provided to potential donors (including
governments and the military) and media, both in
emergency preparedness and particularly during
early phase of emergency response.
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Soliciting or accepting unsolicited donations of
BMS to be avoided. Any donations that havent
been prevented should be collected by a
designated agency under guidance of co-ordinating
body. IF should only be targeted to infants
requiring it. Assessment should always explore
potential for wet nursing or donated expressed
breastmilk.
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Use of IF always to be linked to education, and
practical training about safe preparation Follow-
up should include regular monitoring of infant
weight Availability of fuel, water and equipment
for safe preparation of BMS at household level to
be carefully considered. Where unavailable and
safe preparation and use cannot be assured,
on-site reconstitution and consumption ( wet
feeding) should be initiated
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• Donor agencies considering funding BMS should
  ensure provisions of Operational Guidance and
  Code are met by the implementing agency.
• Interventions to support non-breastfed
• infants should always include a component to
  protect breastfed infants.
• The type and source of BMS should be considered
• Generic (unbranded), and if not available
• Locally purchased
• Home-modified animal milk only as temporary
  measure and as last resort in infants under 6
  months of age.

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IF should be manufactured and packaged in
accordance with the Codex Alimentarius standards
and have a shelf-life of at least 6 months on
receipt of supply. Labels should be in an
appropriate language and adhere to specific
labelling requirements of the Code. Use of
bottles and teats to be discouraged in emergency
contexts Therapeutic milk not an appropriate
BMS
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Where criteria for use of BMS met IF purchased by
agencies working as part of the nutrition and
health emergency response may be used in or
distributed by the healthcare system.
Distribution in discrete manner and not as part
of general food aid to prevent spillover. BMS,
milk products, bottles and teats never to be part
of general or blanket distribution. Dried milk
products only to be distributed when pre-mixed
with milled staple food and not distributed as
single commodity
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In accordance with the Code, provision of single
tins (samples) of BMS to mothers should not
occur, unless that tin is part of assured
continuous supply of formula In accordance with
the Code, no promotion of BMS at the point of
distribution, including displays of products, or
items with milk company logos and BMS supplies
should not be used as a sales inducement.
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In conclusion

• Better Code implementation in general would
  improve IYCF in the context of emergencies
• Donated (free) or subsidised supplies of BMS to
  be avoided. Donations of bottles and teats should
  be refused. Any donations that get through should
  be placed under control of a single designated
  agency.
• Decision to accept, procure, use or distribute IF
  must be made by informed, technical personnel in
  consultation with the co-ordinating agency, lead
  technical agencies and governed by strict
  criteria.

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In conclusion (2)

• BMS never to be included in a general ration. BMS
  only to be distributed according to strict
  criteria and only provided for those infants who
  need them. Use of bottles and teats should be
  actively avoided.
• Operational Guidance articulates well the
  application of the Code in emergencies needs to
  be widely distributed and internalised and
  implemented.