United Nations System
Standing Committee on Nutrition

Working Group on Breastfeeding and Complementary Feeding:  Contribution to Millennium Development Goals (MDGs)

held during the ACC/SCN's 31st Session in New York,  United States, March 2004

Chairs: Miriam Labbok, UNICEF, and Randa Saadeh, WHO (Reina Buijs, Netherlands, unable to attend)
Rapporteurs: Emily Levitt and Lucy Thairu, Cornell University

Part I: Action taken following SCN 2003

During the SCN 2003 in Chennai, the Breastfeeding and Complementary Feeding Working Group accommodated the host organization by inviting presenters of their choice to an informal evening meeting. The WG did not hold a formal meeting at the 2003 SCN, with the understanding that they would receive additional work time in 2004.

In lieu of a formal meeting, a small group gathered and drafted “SCN BF/CF WG 2003 Contribution of Breastfeeding, Complementary Feeding, and Related Maternal Nutrition to the Millennium Development Goals” that outlined contributions of BF/CF to each MDG. This matrix was sent to all participants, with additional columns asking for planned activities to address each goal. While a few organizations did complete the matrix, in general, the responses received noted: 1) since the protection, promotion and support of optimal infant and young child feeding as described in the Global Strategy (GS) for Infant and Young Child Feeding (IYCF) addresses each of the 8 goals, 2) therefore, it was a bit arbitrary to distribute any one specific BF/CF activity against any individual Goal. As a result, the alternative plan for the WG was developed. The new plan was to fine-tune the content of the contribution of BF/CF to the goals, rather than report activities against any one goal, and to address the country assessment plans and future actions in support of the Global Strategy.

In a related effort, a review of the preliminary document addressing planned MDG country assessments found that it included only two IYCF interventions:

• Interventions based on food supplementation for infants (0-2 years)
• Interventions for children aged 5-12 years, which focus on supplementation programs through school meals. Since neither of these addressed the interventions and indicators of the Global Strategy or of BF/CF, WG members were selected to provide input for discussion on additional intervention areas and indicators for SCN to put forward to the MDG country assessment team for consideration for inclusion in all country assessments.

Part II: Outcomes of BF/CF WG SCN 2004 by Objectives 1-4

The Breastfeeding and Complementary Feeding Working Group (WG) was attended by about 200 participants, about 10 from UN agencies, about 20-25 from bilaterals, and the remainder from non-governmental or civil society organisations.

Objective 1: To have consensus and improved definition on the role of BF/CF in support of specific MDGs

The group commented on the 2003 matrix, adding additional essential messages. See Table 1 at end of this report: “SCN BF/CF WG 2003/2004 Contribution of Breastfeeding, Complementary Feeding, and Related Maternal Nutrition to the Millennium Development Goals”

Objective 2: To discuss the inclusion of BF and CF in economic analyses and major planning and funding instruments – Discussant: Meera Shekar, World Bank

• Existing efficacy and cost-effectiveness data are clear on the value of promoting optimal IYCF to reduce poverty indicators.
• Need to make the effort to include nutrition in Poverty Reduction Strategy Papers (PRSPs), Poverty Reduction Strategies (PRSs) and Sector-Wide Approaches (SWAPs) and similar instruments, therefore need for dialogue with the Ministry of Finance, and need to advocate for nutrition in PRSPs/PRSs. Civil society and NGOs can play an important role, especially since many countries are trying to make development of country PRSs into a participatory process.
• While of vital interest to efforts to ensure ongoing support, inclusion of breastfeeding in development or food-security economic analyses remains elusive. The WG is asked to summarize the data that are available for inclusion in these analyses in time for the next SCN. The data would then be more accessible for inclusion into country level and global analyses.
• Appropriate partnership (UN agencies, civil society, bilaterals with no conflicting interest with UN) at the country level is key to getting IYCF into country analyses and larger planning and funding processes (SWAPs, PRSs, and large scale health nutrition, agriculture, community driven development (CDD) and Early Child (IECD) projects and programming.

Objective 3: To offer interventions and measures (“How”s and “How to assess”) for Infant and Young Child Feeding to be included in the MDG country analyses

Following on Jeff Sachs’ request for “specific priorities in nutrition that should become part of these enhanced strategies,” that are "rigorously science and evidence-based, and contribute to these core goals,” the BF/CF WG addressed the development of a list of issues and indicators. Each discussant was asked to comment on the “How”s and offer how to assess the activity in a country assessment. The following list was offered:

Exclusive Breastfeeding: Discussant - Arun Gupta, Breastfeeding Promotion Network, India

Process: Number of health workers trained in support skills for exclusive breastfeeding
Outcome: Prevalence of exclusive breastfeeding in children <6 months.

Continued Breastfeeding: Discussant - Ted Greiner, Sida

Outcome: Economic data, if available, on impact/contribution of continued breastfeeding to national/household food supplies and or to national/household economy Noting that use of existing indicators may simplify data identification, suggestion of: Continued breastfeeding at 12-15 months and 20-23 months

International Code of Marketing of Breastmilk Substitutes: Discussant – David Clark, UNICEF

Process: Have the Code and subsequent resolutions been implemented through effective legislation? Is there an independent monitoring system in place, free from commercial influence? Is the national Code legislation enforced?

Complementary Feeding: Discussant – Chessa Lutter, PAHO

Process: Use a measure of food diversity
Outcome: Underweight and/or stunting at 6-24 months (Note: 24-36 months was suggested, but as many babies are no longer breastfeeding, so, in fact, it is not “complementary feeding” at that time) Anemia 6-24 months;
Ruel/Arimond Index: Discussant – Marie Ruel, IFPRI

HIV and Infant Feeding: discussant – Arjan de Wagt, UNICEF

Process: Utilize the Five Steps in UN document “HIV and Infant Feeding: Priority for Action” s indicators:

1. Develop or revise (as appropriate) a comprehensive national infant and young child feeding policy, which includes HIV and infant feeding.
2. Implement and enforce the International Code of Marketing of Breast-milk Substitutes and sub-sequent relevant World Health Assembly resolutions.
3. Intensify efforts to protect, pro-mote and support appropriate infant and young child feeding practices in general, while recognizing HIV as one of a number of exceptionally difficult circumstances.
4. Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies, and to successfully carry out their infant feeding decisions.
5. Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings.

Multisectoral Involvement: Discussant – Vicky Quinn, LINKAGES, Academy for Educational Development

Process: Has a nutrition Profiles analysis (or similar) been undertaken that shows implications of sub-optimal IYCF and malnutrition on survival, quality of life, productivity, educability, and national development?
Outcome: Does an ‘active’ multi-sectoral group or coalition for IYCF exist either inside or outside of the government to guide policy, enhance program planning, and/or undertake advocacy? Do existing government policies and programs include IYCF? Are IYCF concerns explicitly included in the sectoral policies for agriculture, education, community development, commerce, etc.?

Responsive Feeding: Discussant – Patrice Engle, UNICEF

Process: Do communications materials exist that include pictures of active feeding (or only of food)? Include messages about care? That strengthen the role of care-givers?
Outcome: Surveys of feeding frequency (If available, use indicators on long-tern consequences of IYCF on development and school performance)

Objective 4: To discuss a Goal for 2015

Following on the imperative noted by Dr. Ian Johnson, World Bank, in his Symposium remarks, the WG addressed the “trajectory through 2015” for BF/CF by discussing the possible development of a goal and measurable objectives for this time period. Katherine Kreis introduced the topic and discussion followed.

Is having a measurable goal worthwhile? Discussant – Katharine Kreis, Gates Foundation

Development of a goal is a practical approach if it is realistic, something that “matters”, and based on widely accepted evidence.

Proposed objectives for support of MDGs:

1. “At least 60% of children<6 months of age exclusively breastfed”
Discussion included:

• attention to development of a statement of rationale
• discussion as to whether this is too low or too high (NB. Level in 1990 was about 34% and in 2000 about 39%; this would imply that 60% may be too high to be achievable. Alternatively, it was suggested that this is too low, since some countries have already achieved this level)
• clarity as to the measurement, e.g., cross sectional survey of last 24 hours, and
• the ability to apply it appropriately in different settings. Since the global level is about 40% now, and since the suggested objective is 60% (a 50% increase over 40%), one suggestion was that an objective for a country or setting could be stated as a goal of a 50% increase over level measured in 2000.
• Alternative suggested: Reduce percent of children not exclusively breastfed by half.
• In general, there was agreement with the usefulness of setting an objective, and with this objective as further explained and with suggestion for adaptation.

2. “At least 60% of children 12-15 months of age are still breastfed with appropriate complementary feeding”
Discussion highlighted:

• discussion as to whether this is too low or too high, however, since baseline for this age group is not available, it is difficult to judge
• need to disaggregate “continued breastfeeding” objective from the complementary feeding objective, and if disaggregated, that this would be too low for “still breastfeeding”
• need to include concept that breastfeeding is a contribution to household food security,
• need to consider an additional objective that would increase attention to the related nutritional status and care of the mother, as well as to her role in achieving any BF or CF objective.

Part III: Address structure and function issues of Working Group, and SCN issues

Private Sector involvement of SCN:

There was consensus on the viewpoint that the commercial sector holds different interests (i.e., profits) that are not the interest of SCN, and therefore, should not be part of policy development within SCN. However, recognizing that there will be a process of discussion on this issue, the WG notes that, given the unique experience in addressing the issue of the private sector, any processes on this issue should include representation of this expertise and full inclusion of the issues addressed in the International Code of Marketing of Breastmilk Substitutes.

Action Plan for BF/CF Working Group for 2004:

1.  Should the BF/CF WG have Task Forces (TFs) in light of this year’s discussion?

Three potential Task Forces that came forward in discussion during the WG were:

1. Follow-up on country-level implementation of GSIYCF (tentative chairs: Elizabeth Sterken, Elisabet Helsing) Objective and Proposed actions pending
2. Task Force to provide input on SCN WG issues related to infant feeding to the to UN MDG Millennium Task Force, Co-Chairs: Jay Ross and Michael Latham, with M Labbok as WG Chairs liaison, Suggested members- Arun Gupta, Victor Aguayo, Ted Greiner.

OBJECTIVES: To provide, in a timely fashion, information and recommendations from the WG to the Millennium Project Task Force on Hunger in order to ensure that issues related to breastfeeding (and other infant and young child feeding issues) are properly and adequately addressed both in terms of goals, targets and actions to reduce hunger by 2015.

PROPOSED ACTIONS: A tentative modus operandi is for the Task Force to provide appropriate information and recommendations directly to Meera Shekar and other nutritionally knowledgeable members of the Millennium Task Force, and as necessary engage in discussions with them, and also at other times to feed appropriate materials and recommendations directly to Dr. Pedro Sanchez Coordinator of the UN Millennium Task Force on Hunger, the final decision-maker for this effort.

3. Name of WG and terminology used relating to IYCF (tentative chairs: Beth Styrer/WABA and E Sterken, and diverse group) Objective and proposed actions pending.

Two additional TFs were discussed in the plenary:

4. Iron TF (tentative chair: Nevin Scrimshaw)
5. Growth Chart TF (tentative Chairs: Cutberto Garza and Mercedes de Onis)

All interested TFs are requested to submit statement of objective, membership and suggestion of which WG chair might serve as liaison as soon as possible to the WG Chair: mlabbok@unicef.org.

Please contact the tentative TF chair if you are interested in working on the specified task. See SCN roster for email addresses.

2.  Current Chair and co-chairs have served for at least 2 years. While current chairs are willing to continue if called upon, there has not been an NGO/CSO among the chairs of this group since the current Chair changed status. Participants are invited to submit nominations to Steering Committee of individuals to serve as Chair and co-chairs of WG.

3.  The WG members spoke strongly in favor of maintaining the extant function of WG as vehicle of information exchange and comment amongst partners working towards the same goals. This interest included the possibility of shortening symposium time, or using the earlier hours on symposia days for WGs. Members noted that the activity of an SCN WG is a unique function, providing feedback to the agencies involved, influencing the agenda of the UN agencies, in a forum free of any potential conflict of commercial goals.

4.  WG notes that it volunteered to hold no meeting at last year’s SCN with promise of more time this year. Unfortunately, this additional time was not granted. Therefore, WG requests more time at future meeting(s) to be able to continue coordination and sharing functions in addition to any future specified theme issues.

5.  WG encourages the Steering Committee to consider that the topic of the Global Strategy for Infant and Young Child Feeding be considered for special attention in next year’s meeting, as the Government of Brazil, host of next year’s meeting, has played a major role in the development and approval of this international action plan, and has been highly active in addressing Infant and Young child Feeding within its own borders, serving a s a model to other nations.

TABLE 1

¹ Bhatnagar, S., Jain, N. P. & Tiwari, V. K. Cost of infant feeding in exclusive and partially breastfed infants. Indian Pediatr. 33, 655-658 (1996).
² Dewey, K. G. Cross-cultural patterns of growth and nutritional status of breast-fed infants. Am. J. Clin. Nutr. 67, 10-7 (1998).
³ Anderson, J. W., Johnstone, B. M. & Remley, D. T. Breast-feeding and cognitive development: a meta-analysis. Am. J. Clin. Nutr. 70, 525-35 (1990).
⁴ Jones, G. et al. How many child deaths can we prevent this year? Lancet 362, 65-71 (2003).
⁵ Pelletier, D. & Frongillo, E. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J. Nutr. 133, 107-119 (2003)
⁶ Labbok M. Breastfeeding as a women's issue: conclusions and consensus, complementary concerns, and next actions. IJGO 1994; 47(Suppl):S55-S61