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Statement and recommendations of the joint WHO/UNICEF meeting on infant and young child feeding

The Joint WHO/UNICEF Meeting on Infant and Young Child Feeding took place at WHO Geneva from 9 to 12 October 1979. It was held as part of the two organizations' on-going programmes on the promotion of breast-feeding and improvement of infant and young child nutrition.

The participants included representatives of governments, the United Nations system and technical agencies, nongovernmental organizations active in the area, the infant-food industry and scientists working in the field. A total of some 150 participants was present.

The meeting was conducted in plenary and five working groups. There was one background document prepared by WHO and UNICEF (FHE/ICF/79.3). The themes of the working groups were:

encouraging and supporting breast-feeding,
promotion and support of appropriate weaning practices
information, education, communication and training,
health and social status of women in relation to infant and young child feeding, - appropriate marketing and distribution of breast-milk substitutes.

The Statement and Recommendations below resulted from the discussions of the participants and were agreed upon by consensus.

STATEMENT

The joint WHO/UNICEF Meeting on Infant and Young Child Feeding, which was held at WHO in Geneva from 9 to 12 October 1979, in expressing the need for urgent action by governments, international agencies, nongovernmental organizations and the infant-food industry and health and development workers to promote the health and nutrition of infants and young children, made the following statement:

Poor infant-feeding practices and their consequences are one of the world's major problems and a serious obstacle to social and economic development. Being to a great extent a man-made problem it must be considered a reproach to our science and technology and our social and economic structures, and a blot on our so-called development achievements. It is not only a problem of the developing world: it occurs in many parts of the developed world as well.
The question of adequate nutrition for mankind has been exercising international and national bodies for the last three decades, but the problem of malnutrition is not becoming less. It is taking a heavy toll in deaths and in long-term mental and physical disability. Women, with ;infants and young children, are ;its chief sufferers. This ;is socially, economically and politically unacceptable.
In this International Year of the Child, national governments and the international community are being called upon to focus on this complex problem and to take steps to ensure that children everywhere get a proper start in life on the basis of, inter alia, adequate nutrition. Governments and local communities have a major role to play in supporting action aimed at mothers and children to ensure sound infant and young child feeding practices.
Malnutrition in infants and young children cannot be separated from malnutrition and poor health in women. The mother and her infant form a biological unit; they share also the problems of malnutrition and ill-health, and whatever is done to solve these problems must concern them both together.
The problem is part of the wider issues of poverty, lack of resources, social injustice and ecological degradation; it cannot be considered apart from social and economic development and the need for a new international economic order. It is also a basic issue for health care systems and its solution must be seen ;in the context of Health for All by the Year 2000.
The WHO/UNICEF Meeting on Infant and Young Child Feeding affirms the right of every child and every pregnant and lactating mother to be adequately nourished as a means of attaining and maintaining physical and psychological health. It stresses the responsibility of every society to ensure the effective enjoyment of this right so that children may develop to their full potential.
Breast-feeding 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. This, together with its other important effects, on the prevention of infections, on the health and wellbeing of the mother, on child spacing, on family health on family and national economics, and on food production, makes ;it a key aspect of self-reliance, primary health care and current development approaches. It ;is therefore a responsibility of society to promote breast-feeding and to protect pregnant and lactating mothers from any influences that could disrupt it.
The period of weaning from the breast is a critical stage which often results in malnutrition and disease if the child does not have a diet that is adequate in quantity and quality, hygienically prepared and culturally, socially and economically acceptable.
The health of infants and young children cannot be isolated from the status of women and their roles as mothers and as partners in social and economic development. In poor urban and rural communities where the health and socio-economic status of women is deteriorating, a corresponding deterioration is taking place in the health of infants and young children.
Health for all cannot be attained unless there is a substantial improvement in the socio-economic condition of women, the particular needs of mothers and their infants and young children are recognized and met, and conditions are provided that promote and sustain the well-being of the family. These conditions include the right of women to information and education that will enable them to improve their own health and that of their families and to take an active part in decision-making on matters that affect their own and their children's health. They include also attention to the role of fathers in providing for the needs of their family.
The production, preservation, processing and distribution of food are essential components of any approach to ensuring the proper feeding of families and children. Emphasis should be placed on fresh local foods and traditional practices, complemented only when necessary, and under the guidance of government, by industrially processed products.
The WHO/UNICEF Meeting on Infant and Young Child Feeding affirms the need for sustained national and international action, and for the active participation of families, and especially mothers, in the elimination of malnutrition and the promotion of health. This is a challenge to all social and economic development strategies and to the world community as a whole. In the International Year of the Child it is fitting that national and international efforts be intensified, and that the enthusiasm it has generated in the cause of child health be sustained, to respond to this challenge.

RECOMMENDATIONS

The Encouragement and Support of Breast-feeding

Health care system

Because of the fundamental importance of the health of the mother for breast-feeding, which in turn is essential for the health and development of the infant, and because health services through the primary health care approach, especially where they relate to the health of mothers and children, have an important preventive role to play, it is recommended:

During pregnancy

Every attempt should be made to ensure the sound nutritional status of women and that their nutritional and health needs are met, especially during pregnancy. The health care system in collaboration with other sectors, should help in identifying and utilizing existing local resources so as to ensure that the nutritional needs of the mothers are met.

The health care system in general should ensure that all mothers, particularly during the period of pregnancy, are systematically provided with the type of breast-feeding education that is in keeping with their life situations and presented in practical ways that are likely to enhance their understanding and acceptance of it.

Emphasis should be given to the fact that lactation is a natural biological process but that to some extent breast-feeding is an act which must be anticipated and reinforced. With adequate teaching and support almost all mothers are capable of breast-feeding and solving any problems which may arise. The best teachers will be breast-feeding mothers.

During pregnancy information and guidance should be provided to all mothers concerning preparation for breast-feeding and ways in which they can establish and maintain breast-feeding. The full cooperation of women's groups and other bodies working for the promotion of breast-feeding should be sought and supported by the health care system.

Attention should be given to ensuring that, wherever possible, all health workers in a position to provide adequate information to the mother on breast-feeding should be committed to the promotion of breast-feeding and have a thorough knowledge of its management.

Care should be given during the pregnancy period to identifying those mothers who are likely to be, because of their special social, economic or health condition, at high risk of not breast-feeding and special care should be given to them so as to enhance improvement of their situation and the establishment of breast-feeding.

Delivery

Obstetrical procedures and practices should be consistent with the policy of promoting and supporting breast-feeding. In this respect, unnecessary sedation, routine use of episiotomy, and routine use of lactation suppressants should be avoided.

Breastfeeding should be initiated as soon after birth as possible, normally during the first half-hour and, in order to facilitate breast-feeding, mothers should be permitted and encouraged to keep their infants with them in the same room or close to them and to practise on-demand feeding; maternity routines and structures should be conducive to this practice.

Health-related staff, including traditional birth attendants, should seek to provide mothers not only with educational information but also with practical help and should be provided with appropriate information on the preparation for and management of breast-feeding.

The role of the father and other members of the extended family in providing support for the mother should be emphasized in all prenatal, maternity and postnatal care and fathers should be invited to participate actively with the health team in encouraging the mother to breastfeed.

After delivery

All postnatal health care should be oriented towards ensuring the maintenance of breast-feeding for as long as possible. All babies should receive colostrum. For optimal breast-feeding, the use of supplementary bottle-feeding- water and formula- should be avoided. A healthy well nourished mother who is fully breast-feeding her infant should not need to introduce any complements until after the first 4 - 6 months of life, according to the needs of the infant.

Mothers' nutritional status should be reviewed and, whenever possible, steps taken to ensure that the mother has access to adequate food intake.

The contraceptive effect of breast-feeding should be well recognized, although additional family planning methods should be promoted to ensure birth spacing. Preference should be given to contraceptive methods which do not interfere with the normal process of lactation.

All attempts should be made to ensure that in cases where infants need to be hospitalized facilities are provided so that the mother can be with the infant and continue breast-feeding or that the baby can continue to receive breastmilk. Where it is not possible for the biological mother to breastfeed, the first alternative, if available, should be the use of human breastmilk from other sources. Human milk banks should be made available in appropriate situations.

The terms "humanized" and "maternalized" milk for infant formula should be avoided.

Support through the health services

Health service staff must play a critical role in the initiation, establishment and maintenance of breast-feeding and should ensure that the mother has a source of sustained support for as long as breast-feeding continues, and thus health workers should be well informed and provide consistent information.

A baby who is not breastfed should receive special attention from the health care system. Adequate instructions for the use of infant foods as well as warnings about its problems should be the responsibility of the health care system. Supplies of infant formula would thus be required for distribution only where necessary and not as a routine.

Employed mothers

Paid maternity leave of not less than three months postnatal, job security and economic support should be provided to all mothers whenever possible, and wherever possible, and the responsibility for economic support during maternity leave should be carried by government, the industry in which the woman is working, and other relevant national and international institutions.

Crèches, paid breast-feeding breaks and other facilities should be provided, wherever appropriate, in industry, and in other relevant institutions, or close to the place of work to permit mothers to continue breast-feeding and have close contact with their babies. Financing of crèches and other mechanisms that allow for this continued contact of breast-feeding should be carried by government and/or the industry in which the mother is working.

Community and government support

All channels of communication, including religious leaders, school teachers and other community opinion leaders and voluntary associations, particularly women's organizations, should be actively involved, together with health services and other sectors, in encouraging and supporting breast-feeding and sensitizing the community to the value of breast-feeding and the needs of the mother and baby through home visits, if necessary.

Messages concerning infant and young child feeding should be consistent from one sector to another and from one population group to another, and therefore the promotion of breast-feeding and appropriate infant and young child feeding practices in general should be set within the context of overall maternal and child health practices, national nutrition policies and primary health care.

Governments should be encouraged to set up national expert groups to advise them on policies about breast-feeding and to establish coordinating offices that can ensure consistency and continuation of supportive activities and implementation of ongoing evaluation and monitoring as well as systematic epidemiological research including social factors.

WHO/UNICEF and other organizations should be responsible for encouraging regional and national workshops for the promotion of appropriate infant and young child feeding.

Promotion and Support of Appropriate and Timely Complementary Feeding (Weaning) Practices with the Use of Local Food Resources

Food complementary to breastmilk will need to be introduced by 4 - 6 months; when the nutrition of the mother is poor and/or environmental conditions are unfavourable, it may often need to be introduced earlier. However, too early introduction of supplements may have a negative effect on brestfeeding and may also increase the risk of infection.

The diet of the young child after cessation of breast-feeding needs special attention, because inadequate feeding at this time often leads to clinical forms of malnutrition, particularly when the child is denied the breast as a consequence of a new pregnancy.

In order to guide the mother as to the adequacy of her child's nutrition and the appropriate time to introduce weaning foods, programmes to support her in keeping a graph of her infant's weight and to understand its significance should be extended as widely as possible. The WHO publication "A growth chart for international use in maternal and child health care" provides valuable guidance for doing so.

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 ways. Mothers need guidance to improve these traditional foods through combinations with other foods available to them locally. Countries should determine the need for subsidizing weaning foods or otherwise helping to ensure their availability to low-income groups.

Governments and relevant public or private organizations should support practical and appropriate initiatives and policies for improving the nutritional value and hygienic standards of traditional and other locally used weaning foods, for achieving a balanced diet for infants, for educating mothers in the proper feeding of children, and for facilitating the exchange of weaning and child-feeding experiences among countries.

To avoid infection and interference with continued breast-feeding, infants during weaning should not be fed by bottle but rather by cup and spoon or other suitable traditional vessels and utensils. When mothers do not initiate breast-feeding, or terminate it prematurely, so that animal milk or perhaps vegetable milk mixtures or products may need to be fed by bottle, competent guidance should be available to the individual mothers to ensure that the mixture or product fed is nutritionally adequate, both in quantity and quality, and that all possible measures are taken to see that if does not become a vehicle for infection.

Psychological, social and economic factors that constrain breast-feeding should be minimized.

These questions should be the subject of further research and subsequent scientific meetings.

Strengthening of Education, Training and Information on Infant and Young Child Feeding

Every citizen has the right to have access to correct, consistent information and education; therefore, countries must ensure that information and education be provided to all levels and that the messages reach those for whom they are intended at community, intermediate and central levels.

In all educational (formal and non-formal), vocational and professional training programmes, the interrelationship of all knowledge relating to health protection, breast-feeding and adequate nutrition of the mother, infant and child should be featured.

To ensure maximal effectiveness, educational and informational activities about nutrition must:

- be adapted to local conditions and culture;
- be directed to the target population, viz. schoolchildren, youth, pregnant and breast-feeding mothers, men, community leaders, decision-makers and planners;.
- be supported by necessary resources from those sectors responsible for periurban and rural economic development;
- be undertaken with the active participation of men, husbands, other family members, and community leaders;
- be linked to measures for income-generation at family and community level:
- utilize local cultural methods of communication, such as folk-arts, drama and music.

To support women and mothers in their efforts to improve their health and nutritional status and that of their infants and children, it is important that nutrition education and information be provided to various other individuals who are influential with the family, such as fathers, grandparents, mother-surrogates, community teachers and others who have an impact on the social behaviour and nutritional habits of vulnerable groups, and the education and information should be carried out with their participation.

It is strongly recommended that governments should provide adequate nutrition training in medical and nursing schools, adequate training to primary health care workers, including midwives, particularly in prenatal and perinatal services, school teachers, rural extension workers and others operating at the community level to enable them to undertake functional health and nutrition education in the community, based on the priority needs of the people and with their active participation. The outcome of these endeavours should be increased self-reliance at the community and family level.

It is essential that all personnel who will provide nutrition education be appropriately trained, not only in techniques of communication and education but also in child development and in delivering consistent and coherent nutrition and health concepts and practices based on the local sociocultural conditions.

Training

Basic and continuing education and upgrading of information on all aspects of breast-feeding is necessary for health service staff at all levels, including administrators, professional leaders at medical and nursing schools, physicians (especially obstetricians and paediatricians), nurses and midwives at all levels, medical assistants, auxiliaries, social and extension workers, and particularly primary health care workers. Training should place particular emphasis on management of breast-feeding and be related to the economic, cultural and social background of the mother and family. Training should consist of the appropriate knowledge on available culturally acceptable, locally grown foodstuffs which are suitable for use as weaning foods for the young infant and supplementary foods for the pregnant and lactating woman. Health service staff should also be enlightened about the dangers and hazards of advertising infant foods in clinics.

The use of mass media, which in many countries include radio, TV, newspapers, advertisements for formula and other infant food products, in government and professional journals should be effectively screened by appropriate government ministries to ensure that they do not detract from official nutrition policies designed to protect breast-feeding nor work to the detriment of the health and nutritional status of mothers and children.

There is not enough information about the present state of education/training in the field of maternal, infant and young child nutrition throughout the world. The meeting strongly recommends that this be reviewed as soon as possible and followed up every five years in order to evaluate the activities in this field and to use it for updating the programmes. International organizations, especially WHO/UNICEF, FAO, UNESCO and UNIDO should collaborate in this activity. This also implies collaboration in the preparation of guidelines aimed at identifying problems related to health and nutrition status of mothers and children, particularly regarding conditions of breast-feeding and weaning practices, and on methods of surveillance.

Development of Support for Improved Health and Social Status of Women in Relation to Infant and Young Child Health and Feeding

Status of women- Participation of women

Women's role and experience in infant feeding is unique and the importance of women gaining greater control of actions affecting this aspect of their lives must be emphasized. It is recommended, therefore, that women's participation in all related actions be significantly increased through:

increased representation of women in all follow-up meetings and actions as recommended by this meeting, including increased involvement of women in the activities of United Nations agencies, non-governmental organizations, and other groups, including industry and trade unions;
the increased recognition and involvement of women's organizations in community, national and international efforts, for the promotion of improved infant and young child feeding and related primary health care efforts:
the increased involvement of women in policy formulation and decision-making at ail stages of planning and implementation of related national programmes.

Health and nutritional status of women

Improved infant and young child feeding is closely linked with women's enjoying a high status of health throughout all stages of life, especially in the reproductive cycle. It is recommended that measures be taken to ensure good nutrition and health for all women through:

measures directed towards health care, socially and economically available, particularly according to primary health care, including the provision of balanced and sufficient nutritional intake, especially during pregnancy and lactation, and family planning information and services; special attention should be given to reproductive health and education of adolescent girls with specific action for pregnant adolescents;
the implementation of activities aiming to reduce women's workload, both in the home and outside the home, including actions to promote the sharing of tasks within the family and including development programmes related in particular to the provision of plentiful and clean water and the use of appropriate technologies.

Measures to support women to breastfeed

The woman is pivotal for ail action related to breast-feeding. 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.

The majority of women living in rural areas and in the urban periphery are not covered by protective or legislative measures; they are either not wage-earners or are workers without adequate security. Very little has been done for these women. It is recommended therefore that government action and community development activities, including the help of breast-feeding mothers, be taken to support these mothers to breastfeed. Programmes to develop appropriate technologies (especially regarding food production and handling) to reduce these women's work-load and to organize community-based day care of children should be emphasized.

Governments should ratify and apply the ILO conventions through national legislation concerning maternity protection which are to be developed (and which extend existing protective measures to increase the period of time of maternity leave) for facilitating breast-feeding, including facilities for breast-feeding, paid nursing breaks, flexible schedules, day care centres and other measures to ensure the physical closeness of mother and child; these measures should ensure that women's earnings are not substantially reduced or that complementary measures are introduced to provide subsidies; and that any discrimination of nursing mothers in employment should be prohibited. Women's groups and trade unions should pressure governments to ensure the ratification and implementation of appropriate legislation. The ILO, together with WHO and UNICEF and other United Nations agencies, should continue its activities in the application of legislation and protection of breast-feeding mothers.

Specific educational and nutritional programmes within primary health care should be directed towards pregnant women to prepare them psychologically and physically to breastfeed their baby.

Weaning

Women play important roles in the production, preparation and serving of food within the family. The home preparation of appropriate weaning foods will depend on their knowledge, time, human energy and resources.

In all cases where there is access to local food products, it is necessary to teach women and other family members to use these as weaning foods as part of the family diet;
in cases where women do not have easy access to locally available foods, action should be taken for the organization of community efforts, such as cooperatives, to make such local foods available to women;
educational and other community development programmes related to health and nutrition should be linked with income-generating activities and policies;
all food aid programmes in this area should take cognizance of the local food content and habits, and not create a situation of dependency and should be careful not to compete with breast-feeding and local food production.

Information, education, and training

The importance of an adequate basis on which women can have a true and objective choice emphasizes the need for education and information about infant and young child feeding and for the establishment of measures at government levels to protect women against misinformation. Information and education about infant and young child feeding should be directed to men as well as women in order to enable them to assume their supportive responsibilities.

Educational materials to be directed to the general public, to schoolchildren, and to the training of health and other development workers, should project a positive image of women not only in their roles as mothers but also as workers and citizens of the community. This would refer to the images as seen in books and other written material as well as the mass media.

Women's nongovernmental organizations should organize extensive consciousness-raising campaigns for generating policy actions by governments and launching extensive information dissemination campaigns in support of breast-feeding and good weaning habits. At the local level nongovernmental organizations are urged to organize and carry out women-to-women programmes to promote breast breast-feeding and adequate weaning. In these activities nongovernmental organizations should collaborate with WHO and UNICEF, with the necessary support from national and international agencies.

As in most instances the health care providers to mothers and children are women, special efforts should be directed to strengthen training programmes for these groups of workers to include a comprehensive component of family planning, infant and young child feeding, and other aspects of family health within primary heath care.

For all, education of the public- especially of the young generations - should aim at a better acceptance of breast-feeding as the natural and healthiest practice, taking into account cultural specificities, endogenous practices and using all channels of education as well as the media.

In collaboration with all relevant sectors, particularly health, education, agriculture, industry, governments need to ensure that up-to-date, scientific and empirical information on infant and young child feeding be widely disseminated and applied. A government mechanism must be established to ensure that through continuous screening and monitoring information and publicity relative to maternal, infant and young child feeding are correct and appropriate and that undesirable and inappropriate messages and publicity are eliminated.

A national strategy for communication and education should be formulated to mobilize available resources, this strategy to include training of manpower at all levels to plan, implement, evaluate and conduct research with respect to communication programmes.

Women have the right to correct and full information; even objective information, however, can be misleading and harmful if it is given in inappropriate settings or times. in regard to the marketing of infant formula, women's organizations should be involved in national councils or government agencies in the monitoring and enforcement of marketing codes dealing with the regulation of information and publicity. Women in all parts of the world - in developed and developing countries- should express their solidarity in deciding what is best in this unique and important part of their lives.

Appropriate Marketing and Distribution of Infant Formula and Weaning Foods

The government of each country has the responsibility to promote coherent food and nutrition policies which should give special attention to mothers, infants and children. These policies should emphasize the preservation of breast-feeding and the implementation of appropriate nutritional guidance (calendrier nutritionel). Governments have a duty to ensure the supply and availability of adequate infant food products to those who need them, in ways that will not discourage breast-feeding. Informed advice should be given at the appropriate time and place to mothers and families about best infant and young child feeding practices.

Breastfeeding is the only natural method of feeding babies and it should be actively protected and encouraged in all countries. Therefore, marketing of breastmilk substitutes and weaning foods should be designed not to discourage breast-feeding.

There should be no sales promotion, including promotional advertising* to the public of products to be used as breastmilk substitutes or bottle-fed supplements and feeding bottles.

Promotion to health personnel should be restricted to factual and ethical information.

There should be an international code of marketing of infant formula and other products used as breastmilk substitutes. This should be supported by both exporting and importing countries and observed by all manufacturers. WHO/UNICEF are requested to organize the process for its preparation, with the involvement of all concerned parties, in order to reach a conclusion as soon as possible.

Monitoring of marketing practices is recommended. Usually this will be done under government auspices. Advertising councils and industry, consumer and professional groups can make an important contribution.

There should be no marketing or availability of infant formula or weaning foods in a country unless marketing practices are in accord with the national code or legislation if these exist, or, in their absence, with the spirit of this meeting and the recommendations contained in this report or with any agreed international code.

Facilities of the health care system should never be used for the promotion of artifical feeding. Therefore, advertising or promotional distribution of samples of breastmilk substitutes through health service channels should not be allowed. Artificial feeding should not be openly demonstrated in health facilities.

No personnel paid by companies producing or selling breastmilk substitutes should be allowed to work in the health care system, even if they are assigned more general responsibilities that do not directly include the promotion of formulas, in order to avoid the risk of conflict of interest.

Production and distribution of foods for infants and young children should be governed by strict legal standards. They should be labelled to indicate proper and safe home preparation. Governments should adopt the recommended international standards covering foods for infants and young children developed by the Codex Alimentarius Committee on Foods for Special Dietary Uses and should support the elaboration of standards by this Committee to ensure nutritional value and safety. Governments that have not yet adopted such codes or regulations are urged to do so.

Products that are not suitable alone as weaning foods, such as sweetened condensed milk, cornstarch, cassava flour and cereal flours, should be required by proper regulations not to be packaged, labelled, advertised or otherwise promoted in ways that suggest they should be used as a complement or substitute for breastmilk. For this purpose, vigorous educational efforts should be made against their misuse by mothers.

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