BREASTFEEDING AND THE LAST 50 YEARS GLOBAL MARKERS AND MILESTONES An abbreviated history – 1954-2004

Presented by James Akré Department of Nutrition for Health and Development World Health Organization Geneva, Switzerland

Introduction

If we don’t know where we want to go,

any

path will do. A reasonable corollary is that if we’re not concerned about where we are, there’s no need to bother about how we got here!

But for those who care about breastfeeding – both its present and its future – a quick collective backward glance at the last half-century is at once sobering and reassuring.

If we can agree that we still have a long way to go in establishing optimal breastfeeding as the universal nutritional norm for babies, perhaps we can also agree that we have nevertheless come a long way in achieving this goal.

Judge for yourself on the basis of this highly selective – indeed, intentionally subjective – mix of global markers and milestones covering the last 50 years.

1954

• WHO was only 6 years old.

• UNICEF, age 8, was finally declared a permanent United Nations agency.

• La Leche League was 2 years from its start – at a picnic table in suburban Chicago!

• Ever-breastfed rates were 29% in the USA, 72% in New Zealand and 62% in Tasmania.

• The words “lactation” and “consultant” had not yet been formally linked.

1964

• La Leche League was just 8 years old.

• “Lactation consultant” was an unknown profession.

• WHO was 10 years from adopting its first ever resolution on infant nutrition and breastfeeding.

• The Australian Breastfeeding Association was just being founded.

1974 (1)

• LLL was 18 years old.

• “Lactation consultant” remained an unknown profession.

• WHO adopted its first-ever resolution on infant nutrition and breastfeeding, noting: – the general decline in breastfeeding related to

sociocultural and environmental factors including the mistaken idea caused by misleading sales promotion that breastfeeding is inferior to feeding with manufactured breast-milk substitutes.

1974 (2)

• WHO was 4 years from recommending that all of its Member States give priority to preventing malnutrition in infants and young children by: – supporting and promoting breastfeeding; – taking legislative and social action to facilitate breastfeeding by working mothers; – regulating inappropriate sales promotion of foods used to replace breast milk.

1974 (3)

• WHO and UNICEF were 5 years from convening their landmark first international meeting on infant and young child feeding, which recommended that: – there should be an international code of marketing of infant formula and other products used as breast-milk substitutes.

• The International Baby Food Action Network (IBFAN) was 5 years from being established as a powerful consumer voice for the ethical marketing of processed foods for children.

1984

• 4 years earlier the World Health Assembly endorsed the statement/recommendations agreed at the joint WHO/UNICEF meeting.

• 3 years earlier the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes.

• ILCA had become a twinkle in the eye of its founders, who dared to say “lactation consultant” out loud and with conviction !

• IBLCE was 1 year from being born.

1994 (1)

• ILCA, age 9, with nearly 3000 members in 25 countries on 5 continents, was in official relations with WHO for one year.

• LLLI, age 38, with some 8000 leaders and 30 000 members in 60 countries, was in official relations with WHO for one year.

• 4 years earlier WHO and UNICEF jointly sponsored a meeting that adopted the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding.

1994 (2)

• 5 years earlier WHO and UNICEF issued their joint statement on breastfeeding and the role of maternity services.

• 3 years earlier WHO and UNICEF used their joint statement as the basis for launching the Baby friendly Hospital Initiative (BFHI).

• 3 years earlier the World Alliance for Breastfeeding Action (WABA) was established to protect the right of all children and mothers to breastfeed.

• 2 years earlier WABA organized the first World Breastfeeding Week in a handful of countries.

2004 (1)

• Today, there are over 19 000 BF hospitals in 138 countries, including 41 in Australia , 7329 in China , 2 in Ireland USA , and 50 in , 7 in New Zealand , 42 in the Viet Nam .

• Today, 23 years since its adoption, 165 countries have taken some type of action to give effect to the International Code.

• Today, at age 19 and nearly 4000 members in 51 countries on 6 continents, ILCA is turning the title “lactation consultant” into household words.

• Today, nearly 14 000 IBCLCs are helping to meet the needs of breastfeeding mothers and babies in 59 countries on all continents but Antarctica.

2004 (2)

• Today, at age 48, with leaders in 64 countries, LLLI is the premier community-based support network reaching 100 000 mothers a month.

• Today, with 5 regional offices/more than 150 affiliated groups, IBFAN promotes optimal feeding practices for infants/young children.

• Today, it is 4 years since WHO and UNICEF began developing a global strategy for infant and young child feeding.

• Today, at age 13, WABA is organizing World Breastfeeding Week in >120 countries.

2004 (3)

• Today, it is 3 years since the World Health Assembly urged new approaches to protect exclusive breastfeeding for six months as a global public health recommendation.

• Today, it is 2 years since the World Health Assembly adopted the Global Strategy for Infant and Young Child Feeding.

• Today, WHO and UNICEF are counting on groups like ILCA and LLLI to help make the Global Strategy a reality the world over!

Why, when and how?

• In 1998, the governing bodies of WHO called for revitalization of the global commitment to appropriate infant and young child nutrition, in particular: – breastfeeding – complementary feeding • Work on a new global strategy began in late 1999 and continued until May 2002.

Core principles (1)

A new global strategy should build on past achievements, particularly: • the International Code of Marketing of Breast-milk Substitutes (1981) • the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990) • the Baby-friendly Hospital Initiative (1991)

Core principles (2)

A new global strategy should go further and emphasize: • Comprehensive national policies, including: – Feeding in exceptionally difficult circumstances, e.g. low birth weight, natural disasters and other complex emergencies, refugee settings, internally displaced persons, HIV/AIDS – Health services that protect, promote and support appropriate feeding practices

Core principles (3)

A new global strategy should be grounded on the best available scientific and epidemiological evidence, for example regarding: • the optimal duration of exclusive breastfeeding • prevention of mother-to-child transmission of HIV

Core principles (4)

A new global strategy should be as participatory as possible, thus: • Consultations in Brazil, China, Philippines, Scotland, Sri Lanka, Thailand, Zimbabwe • 6 regional consultations with more than 100 countries, and

ILCA

, LLLI, IBFAN, WABA • Inputs from all 192 WHO Member States • Comments solicited from the food industry

Defining the challenge (1)

• Malnutrition is responsible, directly or indirectly, for 54% of the 10.8 million deaths annually among children under five in developing countries.

• Well over two-thirds of these deaths, which are often associated with inappropriate feeding practices, occur during the first year of life.

Distribution of 10.8 million deaths per year among children under five years of age in developing countries, 2001 ARI 19% Others 28% Perinatal 23%

Deaths associated with malnutrition 54%

Diarrhoea 13% HIV 3% Malaria 9% Measles 5% Sources:

For cause-specific mortality:

EIP/WHO

For malnutrition:

Pelletier DL, et al.. AMJ Public Health 1993; 83:1130-3.

Defining the challenge (2)

• No more than 34% (2000) of infants worldwide are exclusively breastfed during the first 4 months of life (38% in 2004).

• Complementary feeding frequently begins too early or too late.

• Foods are nutritionally inadequate/unsafe.

• Malnourished children are more often sick.

• Rising incidences of overweight and obesity in children are a matter of serious concern.

Aim of the Global Strategy

The aim of the Global Strategy is to improve —through optimal feeding — • the nutritional status • growth and development • health, and thus • the survival of infants and young children.

Objectives of the Global Strategy

• to

raise

awareness of the main problems affecting feeding,

identify

approaches to their solution, and

provide

a framework of essential interventions; • to increase commitment of all concerned parties for optimal feeding practices; • to create an environment enabling informed choices about optimal feeding.

Breastfeeding

• As a global public health recommendation, infants should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health.

• Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to 2 years of age or beyond.

Complementary feeding (1)

Infants are particularly vulnerable during the transition period when complementary feeding begins. Thus, foods should be: • timely - introduced when the need for energy and nutrients exceeds what can be provided through exclusive breastfeeding; • adequate - provide sufficient energy, protein and micronutrients to meet growing child’s nutritional needs;

Complementary feeding (2)

Foods should also be: • safe - hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats; • properly fed - given consistent with a child’s signals of appetite and satiety, and meal frequency, and feeding method should be suitable for age.

Other feeding options

For those few health situations where infants cannot or should not, be breastfed, the best alternative: • expressed breast milk from infant’s mother • breast milk from a wet-nurse or milk bank • a breast-milk substitute fed with a cup depends on individual circumstances.

Infants who are not breastfed need special attention since they constitute a risk group!

Improving feeding practices (1)

Caregivers need access to objective, consistent and complete information, free from commercial influence, about: • recommended period of exclusive breastfeeding • timing of introduction of complementary foods • types of food to give, how much and how often • how to feed foods safely

Improving feeding practices (2)

• Mothers should have access to skilled support — e.g. trained health workers, lay and peer counsellors, certified lactation consultations — to help them initiate and sustain appropriate feeding practices, and to prevent difficulties and overcome them when they occur.

• Community-based networks offering mother to-mother support, and trained breastfeeding counsellors working within/closely with the health care system, have an important role.

Achieving the objectives (1)

All governments should reaffirm the relevance of the Innocenti Declaration targets: • national BF coordinator and committee • maternity services practising the Ten Steps • applying the International Code, and subsequent relevant resolutions of the World Health Assembly • enacting legislation protecting the breastfeeding rights of working women

Achieving the objectives (2)

It should be a priority for all governments to meet the following additional targets: • develop a comprehensive feeding policy • ensure that health and other sectors protect, promote and support appropriate feeding • promote appropriate complementary feeding and continued breastfeeding • consider new measures for giving effect to the International Code and subsequent resolutions

Obligations & responsibilities

Governments, international organizations and other concerned parties share responsibility for ensuring fulfilment of: • the right of children to the highest attainable standard of health care and nutrition, • the right of women to full/unbiased information, and adequate health care and nutrition.

Each partner should acknowledge its responsibilities.

All partners should work together to achieve the Strategy’s aim and objectives.

Governments

The primary responsibility of governments is to: • formulate • implement • monitor • evaluate a comprehensive national policy on infant and young child feeding.

Other concerned parties

• Health professional bodies • NGOs including community support groups • Commercial enterprises • Employers & trade unions • Education authorities, mass media, child-care facilities • International organizations, e.g. WHO, UNICEF, FAO, global lending institutions

Conclusion

The Global Strategy provides governments and other concerned parties with both: • a valuable opportunity, and a • a practical instrument for rededicating themselves to: • protecting • promoting • supporting safe and adequate feeding for infants and young children everywhere.

Now the Strategy needs to be translated into action!

When shall we start?

Many of the things we need can wait.

The children cannot.

To them we cannot answer tomorrow.

Their name is today.

Gabriela Mistral, Chile Nobel Prize for Literature, 1945

Two questions for ILCA and its members

• How can ILCA and its members —acting internationally, regionally and locally —help to ensure full implementation of the Global Strategy?

• How will implementation of the Global Strategy promote the professional development, advancement and recognition of lactation consultants worldwide for the benefit of breastfeeding women, infants and children?