United Nations System
Standing Committee on Nutrition

 

Report on the Meeting of the Working Group on Breastfeeding and Complementary Feeding

Wednesday, 12 April 2000, World Bank, Washington DC
Chair: Lida Lhotska, UNICEF
Rapporteur: Felicity Savage, WHO

Technical Consultation on Infant and Young Child Feeding: Report on the Objectives and Background of the Meeting held at WHO Geneva, 13-17 March 2000.

Randa Saadeh of WHO summarised the objectives of the Consultation, presented the rationale for the development of a new strategy and explained the process leading to the organisation of the meeting.

Nine programmatic themes were presented at the meeting:

  • Measuring trends and progress in infant-feeding practices
  • Increasing rates of exclusive breastfeeding
  • Improving complementary feeding
  • Strengthening and expanding the baby-friendly hospital initiative
  • Integrating support throughout the health care system for appropriate feeding practices
  • Identifying effective models for community support of breastfeeding women
  • Promoting policies and practices to support breastfeeding in the workplace
  • Strengthening implementation of the International Code of Marketing of Breast-milk substitutes
  • Understanding the impact of globalisation on infant feeding

Participants of the Working Group were offered copies of the draft papers on request.

The strategic framework proposed by WHO addresses the following main areas:

  • Exclusive breastfeeding – strengthening current approaches and initiating new ones
  • Complementary feeding – making this a priority on the global agenda
  • Feeding infants and children in exceptionally difficult circumstances, including emergencies and disasters, infection with HIV, and malnutrition
  • The need to identify responsibilities and resources to address the above issues

Discussion focused on:

  • the need to ensure that the new strategy is rights based
  • the statement made by the participants at the Technical Consultation on the evidence suggesting that an appropriate recommended duration of exclusive breastfeeding should be about six months
  • the need for WHO to further review this evidence and to reconsider adopting a global recommendation of "about six months".

Graeme Clugston of WHO reported that a thorough review of all published literature concerning the recommended length of exclusive breastfeeding is underway, and will be submitted to the Cochrane library for high quality endorsement. It is expected that the review will be available in November 2000, and will then be peer reviewed, and submitted to a small expert committee for final endorsement. WHO also expects some evidence from the multi-centre growth reference study to help answer the question. Funds will be sought to enable one or more additional randomized studies to be undertaken.

Rebecca Norton of IBFAN commended WHO for taking action to clarify the issue of the 4-6 months recommendation, because the confusion creates a window of opportunity for inappropriate practices on marketing of complementary foods.

Recommendations

  • Follow up to the Technical Consultation would be the joint responsibility of WHO and UNICEF.
  • Technical questions including the recommended duration of exclusive breastfeeding should be resolved.
  • In the new strategy more attention should be paid to the reality of the conditions of women’s lives in developing countries, and their need for support mechanisms within the community.

Training on Infant Feeding in Emergencies

Rebecca Norton of IBFAN reported on the background and development of two training modules on infant feeding for humanitarian aid workers. This is a collaborative project of WHO, UNICEF, LINKAGES and IBFAN, following a recommendation of an International Meeting on Infant Feeding in Emergencies held in Split, Croatia in 1998. The project is closely linked with the work of the Nutrition in Emergencies group. Recent initiatives to develop clearer policies and guidelines on this issue have revealed many inconsistencies and gaps in the knowledge of humanitarian aid workers on infant feeding, and consequent inappropriate practices, resulting in poor health outcomes among the most vulnerable age group.

The two modules which are being developed are:

  • "Key Issues and Recommendations" to raise awareness about the importance of sound feeding practices in emergencies, for all categories of humanitarian aid workers. Recommended duration 1-3 hours.
  • "Basic Technical Knowledge" about breastfeeding, particularly how to support mothers to initiate and continue the practice, and the appropriate procurement and management of breast-milk substitutes, and their use when necessary. Recommended duration 3-5 hours for health and/or nutrition staff who have completed Module 1.

It is expected that the materials will be field tested in May/June and will be available for wider review in third quarter of 2000. A final draft should be available for dissemination at the end of the year. This is seen not merely as the production of another set of documents, but as the beginning of an active process of education and training of aid workers.

Recommendations

  • Pre-service and in-service training in the subject of infant feeding should be provided for all humanitarian aid workers using the forthcoming modules.
  • Reinforcement of Code implementation in emergencies recognising that violations including unsolicited and insufficient donations, and misinformation, put at even higher risk both breastfed and motherless infants.
 

HIV and Infant Feeding. Joint report by WHO and UNICEF on recent developments

Prevention of Mother-to-Child Transmission of HIV: Regional Meeting of Pilot Projects, Gabarone, Botswana, 27-31 March 2000.

The meeting was attended by representatives from 11 countries in Sub-Saharan Africa, and 3 countries in Central and South America. Felicity Savage of WHO summarized the observations and recommendations of the Working Group on PMTCT and Infant Feeding.

Participants observed that:

  • Breastfeeding protection, promotion, and support, including the BFHI and the implementation of the International Code of Marketing of Breast-milk Substitutes has weakened as a result of concern over the transmission of HIV from mother to infant through breastfeeding.
  • Current messages on infant feeding are perceived as conflicting.
  • Knowledge on the adequacy and feasibility of feeding options is incomplete.
  • Health workers have limited training to counsel women on any of the different feeding methods, or to help them to reach a balanced decision on which option to choose for their infants.
  • Little attention is paid to the need for either exclusive breastfeeding or exclusive replacement feeding, and there remains much mixed feeding.

The meeting participants recommended that national programs with support of WHO/UNICEF/UNAIDS/UNFPA and in collaboration with other partners should ensure that:

  • Training on infant feeding is strengthened and accelerated. The training should include breastfeeding counselling, complementary feeding, infant feeding in PMTCT, and replacement feeding options.
  • Studies on the feasibility of the several feeding options are conducted.
  • Counselling on infant feeding and PMTCT enables the mother to decide what infant feeding option is most feasible for her and best for her infant.
  • All initiatives disseminate consistent messages.

 

"First Regional Training Course on HIV and Infant Feeding Counselling and Policy Development" in Harare, Zimbabwe, April 3-7 2000

Felicity Savage of WHO reported that 7 countries from Sub-Saharan Africa were represented (Botswana, Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe). Three days were spent going through the course, and two days in discussion of policies and plans for introducing the training.

It became apparent that:

  • there is an urgent need for strengthened training in all aspects of infant feeding, including breastfeeding counselling and complementary feeding, before training for health workers to counsel HIV-positive mothers can be conducted effectively.
  • a number of countries lack an overall infant feeding policy, which makes it difficult to develop a firmly founded HIV and infant feeding policy.

Research into HIV and exclusive breastfeeding

WHO has identified this as a priority and has initiated preparation of a protocol.

Three key challenges

Gay Palmer of UNICEF discussed:

  • the difficulty of follow-up of the growth and health of non-breastfeeding children in HIV prevalent countries, and of ensuring that they consume food of the recommended quality and quantity in resource poor families. There has been little research on replacement feeding of non-breastfeeding children in either industrialised or developing countries.
  • the feasibility of counselling and teaching women about safe replacement feeding. There are few staff with the necessary skills and knowledge, and there is a general lack of resources to cover the costs associated with counselling and teaching.
  • spillover of artificial feeding to mothers not identified as HIV-positive is a major concern and as yet monitoring is undertaken in few situations. For effective programming there is an urgent need to know what is happening to breastfeeding rates throughout populations in high HIV prevalence areas.

Discussion centered on the following points:

  • the relative merits of voluntary and compulsory testing, and the right of women to know the HIV status of their partner
  • the growing difficulty of providing resources and training for sufficient counselling as the number of people affected by HIV increases
  • the need to reduce the risk of sub-clinical mastitis in HIV positive women, which would reduce the viral load in milk and thus reduce MTCT
  • that exclusive breastfeeding is also important, and it is necessary to develop strategies to reduce the pressures on women to use replacement feeding or mixed feeding
  • that many governments are ahead of the UN agencies, and have already developed policies.

Recommendations

  • A task force should be formed to address the issue of HIV and infant feeding. One task for the group could be to develop a small methodological guide and ensure systematic compilation of what is effective at the country level.
  • Research is needed on the feasibility and adequacy of infant feeding options including breast-milk options as well as the health and nutrition outcomes in replacement-fed children and their siblings.
  • Programs should support good breastfeeding technique and exclusive breastfeeding, to prevent mastitis and sub-clinical mastitis, to reduce MTCT of HIV.
  • There is a need to allocate health worker time to counselling on infant feeding options, including ongoing support for exclusive breastfeeding or exclusive replacement feeding.
  • The three WHO/UNICEF/UNAIDS documents on HIV and Infant Feeding (Guidelines for decision-makers, A guide for health care managers and supervisors, A review of HIV transmission through breastfeeding) need to be re-launched and promoted – there is widespread misunderstanding of their recommendations.

Report on key 1999 recommendations

David Clark of UNICEF reported progress in the adoption of the rights based approach by all UN Agencies. Although adopted in principle there remain many uncertainties about implementation.

Good progress has been made on reporting the state of the Code implementation and activities on protection, promotion and support of breastfeeding at national level to the CRC Committee. IBFAN has played an important facilitating role in this process.

Recommendation

  • All agencies and NGOs involved in the reporting process to the CRC committee should ensure that country reports address progress on these concerns.

Regarding revision of the Maternity Protection Convention, the SCN secretariat sent the requested letter to WHO to facilitate liaison with ILO on health related reasons for keeping breastfeeding breaks as part of the convention rather than as a recommendation.

Recommendation

  • the SCN secretariat to follow up on this matter.

Concerning strengthening implementation of the International Code of Marketing of Breast-milk Substitutes, UNICEF sent a Program Instruction to all country offices providing practical guidance on how to move forward.

  • Code training manual has been drafted and field tested by UNICEF and is expected to be finalized by the end of 2000.
  • A briefing note explaining the continued relevance of the Code in the context of PMTCT of HIV has been disseminated to all members of the Working Group.
  • The WHO/UNICEF/UNAIDS training course on HIV and Infant Feeding Counselling includes a section on the Code.

Recommendation

  • All relevant agencies and NGOs should endeavour to strengthen Code implementation, including in countries with a high HIV prevalence.

Additional discussion led to a recommendation that other relevant ACC/SCN Working Groups also consider infant feeding issues in their deliberations. As well as the Working Group on Nutrition in Emergencies, which already covers the topic, this would include those addressing Micro-nutrients, Household food security, Nutrition in the life cycle, Maternal nutrition and two new groups on Capacity Building and Nutrition and HIV.