United Nations System
Standing Committee on Nutrition

Working Group on Breastfeeding and Complementary Feeding

held during the SCN's 32nd Session, 15 March 2005, Brasilia

Chair: Miriam Labbok, UNICEF, Invited Co-Chairs: Chessa Lutter, PAHO, Lida Lhotska, IBFAN/GIFA, Rapporteurs: Ted Greiner, PATH, Kaia Engesveen, Abraham Horwitz Lecturer 2005

Part One: Updates on workplan activities

The workplan for the 2004/5 SCN year had two major components:

MDG Task Force
Continued support of the Global Strategy for Infant and Young Child Feeding.

The MDG Task Force Report was presented by Task Force Co-Chair Michael Latham (Co-Chair Jay Ross, and additional members include Victor Aguayo, Ted Greiner, and Arun Gupta). He reported that the Task Force studied all ten MDG reports and looked for mention of nutrition and of breastfeeding, noting deficiencies. Jay Ross drafted comments with the other members on two of them: Hunger and HIV. It was noted that the second version of the Hunger MDG task force (200 pp) had improved on these issues; however, the content changes were not necessarily reflected in the Executive Summary. The Task Force applauded the improvements, but noted that it remained agriculture-related, with perhaps need for more on nutrition and infant and young child feeding. The Task Force recommended they strengthen their Executive Summary regarding high risk of infancy; noting that exclusive breastfeeding and continued breastfeeding with complementary feeding are the interventions that could most decrease IMR. It was clear from the subsequent reports and the “quick wins” that the Task Force did have some influence: a letter was received from the MDG Task Force agreeing that the Executive summary may not have had the proper emphasis although the letter also stated that they felt that it was appropriate overall.

The Task Force noted that they had completed their initial objectives, but were willing to continue to monitor MDG materials concerning breastfeeding and complementary feeding.

Updates on continued support of the Global Strategy for Infant and Young Child Feeding included very brief reports on eight activities:

1. Brief update on UNICEF/WHO collaborations to advance the Global Strategy on Infant and Young Child Feeding – Miriam Labbok: A written summary of UNICEF actions during the last year was distributed. Highlights include work towards revision of BFHI materials to better reflect current knowledge and HIV context, and the development of a Framework for Implementation of the Global Strategy for Infant and Young Child Feeding to be completed in the upcoming year, as well as several HIV/IF materials (contact hendersonp@who.int). In addition, the availability of the UNICEF/WABA Golden Bow (symbol of Exclusive Breastfeeding as the gold standard) and explanatory bookmark from WABA (www.waba.org.my). Innocenti Declaration is 15 years old this year and UNICEF Innocenti Centre will prepare a paper in celebration. Please contact David Clark (dclark@unicef.org).

2. Progress in our host country, Brazil – Marina Rea: Brazil attained a ten-fold increase in exclusive breastfeeding and an increase in median duration to 10 months in 1999; exclusive breastfeeding increased from 3.6 days in 1986 to 35 days today. By 1988 there were four months of paid maternity leave instituted, and five days for fathers. In 1992 there was one Baby-friendly Hospital and today there are 310. The WHO training course and other materials are being actively translated into Portuguese. Today, 27,000 health workers have been trained in 18 hr BFHI course, and a few thousand in other courses. Brazil adopted laws in support of the International Code of Marketing of Breastmilk Substitutes in 1988 and it was revised in 2001 to include all food products given up to 2 years of life. Brazil has been a major actor in the establishment of human milk banks. In addition, there have been many media campaigns and cross-sectoral efforts. Brazil plans a national survey (DHS) at the end of this year.

3. PAHO/WHO efforts to advance the Global Strategy for Infant and Young Child Feeding – Chessa Lutter : In collaboration with UNICEF, national meetings to develop implementation plans for the Global Strategy were held in Bolivia and Guyana and a sub-regional meeting for Central America (Costa Rica, the Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama) was held in Guatemala. In May, a sub-regional meeting will be held in Argentina and include Paraguay and Uruguay; a sub-regional meeting for the Caribbean is planned for October. A sub-regional meeting for the Andean countries is also being planned. To ensure the integrated actions necessary to implement the Global Strategy, representatives of the Ministries of Health in nutrition and child health (IMCI) are invited to each meeting, and, depending on funding, PMTCT representatives are also included with invitations are extended to all interested stakeholders. The meetings emphasize the GS as well as anaemia, linear growth, the new WHO growth standards, and the critical importance of optimal breastfeeding and complementary feeding practices for reaching the MDGs. Follow-up visits to Bolivia, Guyana, and Honduras are planned this year to monitor the implementation plans. Related issues:

In the sub-regional meeting in Guatemala, a round table was held with three private sector national Guatemalan companies, two producing fortified complementary foods and one producing iron compounds. A number of countries expressed interest in working with these companies to promote the development of a high-quality low-cost fortified complementary food for the commercial market. With representatives of IBFAN, a frank and constructive discussion was held about the roles and obligations of the private sector to ensure that such foods were marketed in the context of strong Code legislation and include messages on the label about the importance of continued breastfeeding and use of family foods.
PAHO and UNICEF, among others were invited to a small meeting at the Gates Foundation to explore how the Foundation might support IYCF, with a focus on public-private sector collaboration for the development and social marketing of high-quality low-cost fortified complementary foods while recognizing the importance of simultaneously promoting breastfeeding and optimal feeding practices.
It was noted that the PAHO/WHO document on the Guiding Principles for Complementary Feeding of the Breastfed Child has been adopted for the Brazilian context, ensuring that consistent infant and young child feeding messages are being transmitted in the Region of the Americas.

4. Efforts to assess IYCF actions in the Indian Ocean Crisis – Lida Lhotska: The Infant Feeding in Emergency (IFE) Core Group has developed a set of materials comprised of the IFE Operational Guidelines and 2 sets of training modules. Module 1 is a 1-2 hour course targeted for all emergency staff. The SCN meeting was an opportunity to launch Module 2 which is for all health and nutrition humanitarian workers. Module 2 helps build knowledge and skills and should be given following Module 1. Both modules are built on the principles “do no harm”, “protect beneficial practices”, and “provide active support for breastfeeding”. These modules were advanced for use in the recent Indian Ocean Crisis by ENN, CARE/USA, UNICEF, IBFAN, and others, and an interagency effort is underway to evaluate the implementation of infant feeding interventions in this crisis. The voluntary “Guidelines to support progressive realization of the right to adequate food in the context of National Food Security” is clear on the importance of breastfeeding. This is consistent with the CRC that highlights the importance of breastfeeding for the realization of the right of the child to the highest attainable standard of health. The GSIYCF also has a human rights based approach with special attention to IYCF in emergencies and emphasizes the need to pay special attention to the feeding of infants and young children and to the support of their caregivers, including in exceptionally difficult circumstances, such as emergencies. Adequate food for IYCF in emergencies should be the same as “appropriate infant and young child feeding” as defined in the Global Strategy. Material available at www.ennonline.net

5. Report on a URC-hosted meeting on HIV/Infant Feeding in Tanzania – Miriam Labbok: A two day meeting of researchers on the Balance of Risks in HIV and IF was developed and hosted by URC/USAID and a follow-on 2-day meeting with Tanzanian program implementers followed. Invitees included a wide regional representation of studies ongoing in the Sub-Saharan countries. The meeting was designed to explore implementation of the WHO/UNICEF/UNAIDS/ UNFPA policies on HIV/IF, taking the local context and findings into account. There were at least six general recommendations for action proposed by the researchers:

For a mother to make a truly informed choice, counselors must present an evidence-based, locally appropriate balance of risks of mortality from HIV or from other endemic diseases that are associated with each feeding choice. Therefore the group recommended that there be a reverse in the conceptualization of HIV/IF, to be rather “infant feeding counseling in the context of HIV”, with initial presentation of the relative survival with existing feeding approaches used in the general population becoming the first issue presented to the HIV+ mother, prior to presenting the risk of HIV-transmission.
Counselors, as well as mothers, should have the best available knowledge and be clear as to what the risks are, and how to reduce risks to HIV-free survival.
There was consensus among these researchers that sufficient data exist in the region to say that mixed feeding (as opposed to exclusive or nearly exclusive breastfeeding) in first few months may increase risk of HIV transmission via breastfeeding.
Capacity of counselors to know and to convey these messages must be addressed.
Increased follow-up is needed, and any study with follow up of HIV-infection is called upon to also assess overall survival – HIV-free survival – by feeding pattern.
The model for estimating the balance of risks published in AJPH was fully explored and discussed, and with recognition that there are at least 8 biases against the choice to breastfeed and at least 2 biases against the choice to not breastfeed, that the model was deemed very acceptable for advocacy and discussion.

6. Update on the new growth charts based on healthy and breastfed infants – Cutberto Garza: The new standards based on the results from WHO Multicenter Growth Reference Study that were presented in plenary are based on children exclusively or predominantly breastfed for at least 4 months and continuing breastfeeding for at least 12 months with introduction of complementary foods by the age of 6 months. It is suggested that the new growth charts will describe “how children should grow”, or, in other words, will serve as a “standard” rather than the reference tables that were previously in use. It is designed to serve as a clinical tool, but also as an advocacy tool and management tool. They will provide better description of weight and development based on more data points. The main message is that programmes will no longer look at the healthy breastfed child as falling off the chart when, in fact, it is healthy and normal growth.

7. Sharing of Unilever-UNICEF collaboration on complementary feeding in the Region – Marti van Liere, Unilever, with additional comment by Osvaldo Legon, UNICEF; Dr. van Liere noted that Unilever has a Health and Nutrition Institute, and has 130 scientific staff including >30 nutritionists. The global partnership between Unilever and UNICEF has been ongoing in several regions, addressing micronutrient issues. The current project is designed to address MDG 4: to reduce <5MR by reducing malnutrition in the first two to three years of life. Both organizations express a long-term commitment to economically sustainable nutrition and hygiene solutions, varying by region. In Central and South America the collaboration will focus on CF, and will begin with a Unilever-supported, UNICEF Regional office hosted, and UNICEF Country Office implemented survey of low-cost commercial infant foods, their spread, utilization. This will be analyzed by Unilever in terms of potential for impact on nutritional status. The situational analysis will contribute to building a business case, on the basis of which Unilever Latin America will decide, or not, to develop such an affordable, high quality complementary food. The intention is to develop background information to inform the production of a complementary food with an optimal composition that is still affordable. The product will be designed for complementary feeding, for infants and young children above 6 months of age and will be marketed in a manner to support optimal breastfeeding. Dr. Legon noted the importance of partnerships such as this to meet the variety of needs in the region, and to fill a current gap in products available.

8. Breastfeeding/complementary feeding issues in the Voluntary Guidelines and in Rights Discussion (Draft brief prepared by David Clark) and in the greater child and human rights discussion – Lida Lhotska: The draft, designed to present issues related to breastfeeding, complementary feeding and the Code of Marketing, was considered. Breastfeeding is mentioned specifically in Voluntary Guidelines 10.1, 10.5, and 10.6. There is some concern that the optional nature of some of the provisions, in addition to the voluntary nature of the guidelines, may undermine existing commitments. However, while the drafters of the Voluntary Guidelines gave assurances that nothing in the Voluntary Guidelines is weaker than the provisions in the existing international instruments, the Voluntary Guidelines should be seen as a clarification tool that does not supercede these instruments. (The draft brief notes a need to continue discussion of this issue and further clarify the above.)

WG Discussion on all presentations:

A very rich discussion ensued in the two discussion periods. Issues noted were: 1) SCN involvement in support of breastfeeding/complementary feeding in MDG meetings; 2) the importance of exclusive breastfeeding/continued breastfeeding/complementary feeding in combating stunting; 3) concerns about the importance of use of, and maintenance of, the practices related to locally produced complementary foods, in contrast to internationally produced complementary foods, and the impact of availability of commercial foods on the variety of foods consumed; 4) Nestlé Code violations and other private sector support for policy and programmes, including the role of private sector in the Working Group; 5) bases, conditions, and appropriateness of the relationship between Unilever and UNICEF; 6) the importance of differentiating between complementary feeding and complementary foods and the possibility of ensuring Codex regulations on complementary foods are adequate; 7) the new energy requirements for complementary feeding; 8) life-cycle issues; 9) sufficiency of iodine in breastmilk of depleted mothers; 10) how to translate evidence-based recommendations on the balance of risks of HIV transmission via breastfeeding vs risks associated with not breastfeeding to be better understood by both counselors and mothers, and practices that might avoid the “economic incentive” of free formula.

Part two: Recommendations for SCN and for the Work Plan of the Working Group

Ten specific suggestions were raised, however, while the session was split into 45 minutes of presentations and 45 minutes of discussion, there was no time for discussion of the recommendations. Therefore, the first recommendation is to:

1. Increase/double the time allotted for working group work, in whatever manner possible, in order to allow sufficient time for the work of the working groups.

The other suggestions are primarily drawn from the comments of the presenters, but were not properly discussed with the group. These include:

2. Prepare a refereed-journal paper on IYCF in relation to MDGs based on last year’s Working Group matrix.

3. Continue and enhance collaboration with SCN Working Groups on Nutrition in Emergencies, Nutrition and HIV, and Capacity Development in Good and Nutrition.

4. Invite further review of the two IFE modules as living documents, for ongoing update.

5. Support the interagency effort to complete questionnaire to document IYCF in the Indian Ocean Crisis.

6. Form a task force on Infant Feeding in the context of HIV to work in support of UN agencies’ efforts to put the existing policies into practice, including addressing the balance of risks among infant feeding options.(If interested, please contact Miriam Labbok, mlabbok@unicef.org, until task force Chair is selected)

7. Continue the MDG task force for at least one more year to monitor MDG process concerning IYCF.

8. Encourage and support the use of the new growth standards in all growth monitoring, BF and CF promotion activities.

9. Request SCN and this WG establish a platform for dialog with private sector. (Following energetic discussion, it was suggested that this rather be a task force on complementary feeding, local and food based or manufactured.(If interested, please contact Miriam Labbok, mlabbok@unicef.org, until task force Chair is selected)

10. Form a task force breastfeeding/complementary feeding and Rights. If interested to engage in work of this task force please contact task force Chair David Clark, dclark@unicef.org.

Part Three: Work Plan and the Way Forward

Many thanks were expressed to the Host Country and to Marina Rea for her presentation on Brazil, and thanks to the Temporary Co-Chairs and the Rapporteurs.

Workplan:

There was no discussion of the Working Group composition or leadership. However, all chairs have been in these roles for at least three years, so, according to the 2000 SCN Strategic Plan, all posts are open for reappointment. If this is not carried out by the Steering Committee, current and temporary chairs will discuss future roles within the next four months.
The MDG task force has defined its more limited continuing role, and at least two new task forces will be formed (1) Rights and (2) Complementary Feeding, and, perhaps, (3) Balance of Risks in HIV and Infant Feeding. Each of the task forces will be asked to submit objectives for Chairs and SCN consideration by mid-June.
SCN is asked to assist the Working Group in collaboration with the Working Group on Nutrition in Emergencies in the interagency assessment of IYCF in the Indian Ocean Crisis.
In planning of the next Working Group meeting at SCN, (1) every effort will again be made to have all activity updates submitted electronically at least one month prior to the dates of 33rd SCN in 2006, and (2) every effort will be made to address fewer topics and to retain the majority of the allotted time for discussion and forward planning.

Respectfully submitted 30 March 2005 by WG Chair, based on initial input from Rapporteurs and editing by Invited Co-chairs and speakers.

United Nations System Standing Committee on Nutrition